NCC203689_NOT Signed Certification_20211101

C 01 Notice of Termination (NOT) a rtif i cation Form
Directions:
Rri nt t his for m, cam plete, sca n a nd v ploa d to th e e I ectran in N OT (Rescission) for rn.
Then, rnaiI the arig!naI form to the NC DEMLR Storrnwater Progrern at:
Division of Energy, Mineral & Land Resources Stoat water Program
512 N. Salisbury Street, 6"' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Perm -it Certificate of Coverage ( OC) O.:
Name of Project- _ Anderson Creek Oros-5ing, Phase 8, Section ZB - Lot 102
Per N C Gen eras Statute 143-215.6E (i), arry person who kno win g)Y m ukes any false s tatemerr � represen to trorr,
or certification in any oppfica tfan, record, repo rt, pion, o r c ther locum en t1led o r requ Fred to b e rrru in rained
under this Arricle or c rute implementing this Artfcfe , , _.chaff be 9 uif ty of a Floss 2 m isdem ecrrar which rya ay
include a fine rrat to exceed tern rhaasond dollars ( 10, O).
U rid er pen a Ity of law, 1 ce rtify that:
I, as an authorized representative, here4y request rescission of r-overage under the NPOES
Storrnwater Permit for the subject facility, l am familiar with the information contained in this
re q ue st, a n d to t h e best of my k nowledge a n d be I i ef, such i nfo rrrr ati on i s true, corn plete, a nd
accurate,
Legally Responsible Organizational Entity.
Gayness & Cates Building and Development Company
* Legally Responsible Person; Christopher E. Cates
Title of Legally Respo bie Poon; Vice President
Signature: [)ate; 1111/21
* iMPOR TA NT NO TE: This form mum t be srg oed by a rasp onsfbfa corpor'o to Officer that own s or opera tes th e
coostructiorr activity, such as o president, se-cretary, treasurer, or vice presiderrr, or 0 manager that is
authorized irr accordance with Part f , Sealer, 6, item (6) of the NCC;010000 permit,
For more informa ri on on srgauto ry requi ramie,, ts, see Port IV, Section 8, iterrm (6) of the NCG01 0000 p ermit,