NCC213723_NOT Signed Certification_20220609

NC601 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Res ciss+ori) furm.
Ihen, marl the otionof signed form to She NC 0 L M L R 51orrnivater Program aI:
Diwnian of Energy, Mineral & land Resources Slormwater Program
512 N. Salisbury Street, G"- Floor
1612 Mail Service Center
Raleigh, NC 27699.1612
❑O NOT MAIL 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 122,221
General Permit Certificate of Coverage (COCJ No.: ^NCC;213723
Name of Project: The Preserve Lot 610
Per NC Gen cral 5 far ul e 143 2I5.68 (i), any person who knowingly makes any fai5e staremenr, represerffolion, or
ctrr+fica(iun in any applpcabon, record, report, plan, or arher document fried or required to be mom Iward under [firs
Artxle or a rule impfermnfin g IM5 Arficle . , . shall be guilty of o Class 7 niisdrtivanor which nioy include a fine not
to exceed fen thousand dollars (510 ODO).
Under penalty of law, I certify that:
I, as arr authorised representatrye, hereby regLies t rescission of coverage under the N P D E 5 Stormwater Permit far
the subleci facrliIV. la in famrfior with t1w information contained in this request, and to the hest of my knowledge
and belief. Such information is true, complete, and accurate.
Legally Responsible Orgarsicational Entity:
1
• Legally Responsiblie Persarr
Title of Legal
'Signature:
M
land Title of Sign (only if outhonted individual signing differs from Legally Resp6nsibfA(Person1:
IMPORTANT NO TIE. Ibis form must do signed by a respons+bk corporate officer chat awns or oprroits the
con5it" tion octrvicy, such os a orrside"t, sccrclary, freasarcr, or Vice presidenf, air a rnoriogcr that is auftritcd in
accordoncr with Part IV, Secrion 8, Item 16)1 of the 1VCGOI0000Ix•rmit.
For more information on signatory rrGuirrnscnts, we Part 1V. Section 8, Item (6) of the NCG010000 Permit.