NCC204735_NOT Signed Certification_20211208

NCGO1 Not4h
ice of Termination (NOT) Certification Form
Directions:
Print this form, co rn plete, scan and upload to the electronic NOT ( Rescission) form.
Then, mall the original signed form to the NC D E I LR Stormwater Program at.
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6�' Floor
1612 Mail ServEce Center
Raleigh, NC 27 699-1617
DO NOT BAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.2-21
General Permit Certificate of Coverage (COC) No.: NCC204735
Name of Project: _chapel ridge -lot 13
Per NC General Stotute 14.E- 1 . 8 N, any person who knowingly mokes any false staterrient., representotion, or
certification in airy oppfication., record, report, pion, or other document fifed or required to be maintained under
this Article or a rule lm, iemerrtrng this Article, , , shali be guilty of a Class 2 misdemeanor which may incfide o fine
not to exceed tea thousand dollars (10, 000).
Under penalty of 1-a, I certify that.
IF as are authorized repriesentative, hereby request rescission of coverage under the NPIDES Stornnwater Permit for
the subject facility. I am familiar with the information contained in this requestf and to the best of my knowledge
and belief, such information is truer complete, and accurate.
Legally Responsible Orgy nizationa J Entity. ,Cha rn herl a i n Homes
*Legally Responsible Person, Franklin Barbee
* Title of Legally Responsible Person: Owner
*Signature: date: 1 .8.21
*Print Name and Title of Signed (onlyif authorized individual Sign ng differs ra Legali �espansihle Person)'
* I PO RTA NT NO -rE: Th is form mus t h e sign ed h y a responsible core orate officer th a t o erns or operates th e
cons rust o n activity, su car os a preside n tt se cre to ry, tre usurer., or v ice presf dery t, or a m onager that is a u th orrze d in
accordance w1th Par-t IV, Section 13, item (6) of the NCG010000 p e rm r L
F0r rrr 0re inform Darr o tlo n on sign o tor} r equ 1remerrts, see Part I V, Sec ti on B, Ite m (6) of th e N C O10000 permit.