NCC204954_NOT Signed Certification_20220505

NCG0J. Notice of Termination (NOT) Certification Form
Directions:
Print t iis form, complete, scan and upload to the electronic NOT (Rescission) form.
n, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC204954
Name of Project: I Brookwood Subsdivisi
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:
® 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 Responsible
* Legally Responsible
nizational Entity: Caviness & Cates Building and Development Company
on:
Christopher E. Cates
Title of Legally Responsible Persg(r-)F# President
Signature:
5/5/22
*IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, uch as a president, secretary, treasurer, or vice president, or a manager that is
authorized in accords ce with Part 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.