NCC201936_NOT Supporting Documents_20230619

NCGOI Notice of Termination (NOT) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOT(Rescissicrri form,
Then, mall the original signed form to the NC DEMLR Stormwater Program 3t.
Division of Energy, Mineral& Land Resources Stormwater Program
512 N.Salisbury Street,6"floor
1612 Mall Service Center
Raleigh, NC 17699-1612
DC)NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED
f HE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL)J40 CFR 1)7 2YJ
General Permit Certificate of Coverage (COC) No.: NCC201936
Name of Project: Trinity Forest
Per NC General Statute 143-215.6d(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 nut
to exceed ten thousand dollars(510,000).
Under penalty of law,I certify that:
I, as an authorved representative,hereby request mission of toyerdije under the NP1WS Sturmwatr•r Permit fat
the ,ubirlt facility. I am familiar with the information contained in this request,and to tlw best of my knowledge
and belief,such information is-true. complete,and accurate
Legally Re--ponsitile Organizational Entity(must match eNOT): Doullen, LLC (Typo: Douatlen, LLC)
'Legally Responsible Person(must match eNOT): John Dougher
•1 rile of Legally Responsible Person: Member
Print Name&Title of-Signed if Authorized Individual Differs from Legally Responsible Person
Aleece Trahan Dale, Secretary, Doullen, LLC
'Sipn.rturi2 L • • ' 6/19/2023
` Date.
IMPORTANT NOTE: rhis}arm must be signed by a responsible corporate officer that owns or operates the
construction activity,such as a president,secretary, treasurer, or vice president,or a manager that h authorized in
accordance with Part iV.Section B.Item(6)of the NCGOI0000 permit.
For more informatu n on signatory requirements,see Part IV, Section 8, item(6)of the NCG01O000 permit.