NCC201146_NOT Signed Certification_20230320

NCG01 Notice of Termination (NOT) Cer#ificafion Form
Directions:
Print this forme c mL,f�t-e, scare ;p n-d upload to the eler Ironic NOT (f i-scissfcin) form_
Then, nail the on&ui sign -Ed form to the N C DEMLR Stormvwater Pragra m at_
Division of Energy, Mineral & La nd Resources Stornrwater Program
512 H. Salisbury Street, 0 Froor
1612 Mail iervi[e Cerrter
Raleigh, NC 27689-15IZ
DO NOT MAIL THIS FORM UNT1 L YOU R NOT REQUEST HAS BEEN RfVI EWER AND AP PROVED.
THE FORM YOU NEAT L MUST RE COMPLETED WITH AN OM(;II% AL $IGNATURE (NnT DJGITALM [4G CFR 122.22]
Genera I Permit Certificate 4 Covera E�e � CC Q No.;
Name of Project_
VWNSW Greek
W X;ZU 1140$
Per KC rear( -5tiptutr 143-215.60 (i), any person who ikrwwrrngiy motes orry fakse statement, representation, or
Eartifrmaan in any appi caG m' plan, ar other doctor nt rk-d or required to be rr ufntained -under this
Article or a ry a irrr&rfaenting gees Artkie . - - ShL710 .�e guiflyr of o Gass 2 miWffineoraor which may hviude o free rwf
to exceed Lee: ttxqLwnd doffiars t$1.0 tom).
LJnder penalty of law, i certify that:
i, as an a uthorized representathe-Pr hereby request rescission of coverage udder the Nilm!S Stormwater Permit for
the subj ect facility- L a m to m ilia r with the information contained in this req Ue-Str a nd to the hest of my knflwledge
and belied, sucl7 i i1formation is true, complete, and accurate.
Leg -ally R-esp4nsibla Organ izatiDnal Entii -
Triple A Homes
wLegaltV Responsible Person: L�ur� pars - V
Titry of Legally Respon$ible Person' _--
*sign at re Date: 3rz 3
Print N am a and r ltle of Signed ?oral' indiWi+oi .5 igninq deers from LegoiJy ResponsiWe Person):
* 1J1 F0WAJWT NEE' ThiSform must be signed by a responsible corporate officer tier# owns or opero€es the
construaiM cc'>rrvity. su h as o pTekclent secretary, treasurer, or vke presideror a manager t+vt rs puthorized in
acco rdarwe with part JV, Section 8, !terra (6) of ttne NCG010" perrm L
vor o»are information on signatory requiremenM see Part IV, Srreborp 8, itcm (6) of ttm N 3 GLOM pVmr't.