NCC202977_NOT Signed Certification_20210818

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOT(Rescission)form.
Then, mail the original signed form tothe NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 0' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122.221
General Permit Certificate of Coverage (COC) No.: NCC202977
Name of Project: Reeds Cove on Lake Norman
who knowingly makes an alse statement representation, or
Per NC General Statute 1�I3-215.68 i an person any false p
(), any 9Y
ion in an application, record re !an or other document or required to be maintained under this
certification y pp report, p ffled R
Article or a rule implementing this Article. . .shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subject facility. I am familiar with the information contained in this request, and to the best of my knowledge
and belief, such information is true, complete, and accurate.
Legally YRes Responsible Organizational Entity
JBH Develo
pment,ment LLC
*Legally Responsible Person: J. Bart Hopper
Title of Legally Responsible Person: Manager
*Signature: r! Date: $ YL2(
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
J&,k+ Kc ta?p - ASStS c4,4- ry%-v-Ja r
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity,such as a president, secretary, treasurer, or vice president, or a manager that is authorized in
accordance with Part IV, Section B, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NCG010000 permit.