NCC212118_NOT Signed Certification_20220505

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
hen, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC212118
Name of Project:
Per NC General Statue 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:
® I, as an auth rized 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
nizational Entity: Caviness & Cates Building and Development Company
* Legally Responsible Person:
Title of Legally Responsible
Signature:
*IMPORTANT NOTE: 1
construction activity,
authorized in accorda
Christopher E. Cates
Vice President
5/5/22
form must be signed by a responsible corporate officer that owns or operates the
h as a president, secretary, treasurer, or vice president, or a manager that is
with Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information I on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.