NCC201614_NOT Signed Certification_20220418

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 form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
S12 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (CCQ No.: NCC201614
Name of Project: Corporate Hangar
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report plan, or other document filed or required to be maintained
under this 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:
1, 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 Responsible Organizational Entity:
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*Legally Responsible Person: Heather Hamby _
Title of Legally Responsible Person : VP, Corporate Project Lead
*Signature:/�(}` # t��L 7 Date: 4/18/22
Print Name and Title of Signed (only if outho4ed individual signing differs from Legally Responsible Person):
* 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 Port IV, Section 8, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.
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