NCC202059_NOT Signed Certification_20230904

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 form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N.Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC202059
Name of Project: Duck Thru - Morgans Corner
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: Harrell Acquisitions, LLC
*Legally Responsible Person: James M. Harrell
Title of Legally Responsible Person: Manager, Harrell Acquisitions, LLC
*Signature: (K. (11,/ Date: er- — �3
Print Name and Tit e of Signed (only if authorized individual signing differs from Legally Responsible Person):
3an,es el. /lap-re1( / treen
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* IMPORTANT NOTE: This 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.