NCC214404_NOT Signed Certification_20220808

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form_
Then, mail the an rral signed farm to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 5"' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO 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) 1*0 CFR 121221
General Permit Certificate of Coverage (COC) No., NGU21,4"=04
Name of Project: Astiley Wvcds Subdivision Lot 3
Per NC General Statute 243-215.60 (i). any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or otherdocurnent 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 aline not
to exceed ten thousanddoilars ($10,000).
Lander penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subect 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_ Judy S°rum
'Legally Responsible Person: JutTy Strum
Trrtle of Legally Responsible Person: l
*Signature: _ Date-
Print Naive and itle of Signed [only if authorized individual signing differs from Legally Responsible Person):
IMPORTANT NOTE_ This form must be signed by a responsible corporate of ecer 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 Part. iV, Section 8, Item (61 of the NCG010000 permit,
For more information on signatory requirements, see Part 1 V, Section 8, item f 6) of the NCG010" permit.