NCC201661_NOT Signed Certification_20230705

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOT(Rescission) form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral& Land Resources Stormwater Program
512 N. Salisbury Street, 61h 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) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: NCG010000
Name of Project: McMillian Farm Subdivision
Per NC General Statute 143-215.6E(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 not
to exceed ten thousand dollars($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater 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): mew wag, . tA. )L4.604 r ,
*Legally Responsible Person (must match eNOT): �Q� .r elIk 't--vl
*Title of Legally Responsible Person: Nke '\ a- .
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: MAvALAMti. M.AN ( Date: 1 " 5 - ZoZ3
* IMPORTANT N is form 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 is authorized in
accordance with Part IV, Section B, Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, item(6)of the NCG010000 permit.