NCC230587_NOT Signed Certification_20231204

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.: NCC230587
Name of Project: Brookwood lots 41,48,54,55
Per NC General Statute 143-215.68(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:
d 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: Caviness Land Development
* Legally Responsible Person: Watson G Caviness
Title of Legally Responsible Person: President
Signature: w Date: INLI)a3
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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.