NCC215685_NOT Signed Certification_20230605

NCGO1 Notice of Termination (NOT) Certification Form
Print this form,complete,scan and upload to the electronic NOT(Rescission)form.
Then,mail the erIglnol signed form to the NC WWI Stormwater Program et:
Division of Energy,Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,ie Floor
11112 Mail Service Center
Raleigh,NC 21F/19,1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BUN REVIEWED AND APPROVED.
INS?OVA YOU ARIL MUTT tK COMM:,WITH AN OAIG M*swung lMOT WQllMt1 140 CM l27,1II
General Permit Certificate of Coverage (COC) No„ NCC215685
Name of Project; Johnsen Residence
Per NC General Statute 143•215.68(I),any person who knowingly makes any false statement,representation,or
certification In any application,record,report,pion,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(510,000),
Under penalty of law,I certify that:
I,as an authorized representative,hereby request rescission of coverage under the NPOES Storrnwater 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 Organizational Entity(must match eNOT): Tate Rice Homes, Inc
'Legally Responsible Person(must match eNOT): Tate Rice
'Title of Legally Responsible Person: President
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
'Signature: Date: 6/5/23
•IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity,such os o president,secretary,treasurer,or vice president,or a manager that Is authorized In
accordance with Part IV,Section 8,Item(6)of the NCG010000 permit.
For more Information on signatory requirements,see Port IV,Section 8,Item(6)of the N00010000 permit.