NCC211491_NOT Signed Certification_20240228

NCGO1 Notice of Termination (NOT) Certification Form
Direr -
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,6th 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.: 1\ CC,2\ \ LA 431 t
Name of Project: C M \\. V �ktn-cc:- \`—DOM=1Q— (2c-,CS
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: �VIA k\ \ -v Pk::::-5 - a C_
*Legally Responsible Person: t� L� Pc f--Qz_ci
Title of Legally Responsible Person: Ne--G�-1---b6t*Signature: e.7ir'-r f---- -�� �,.ram.r. Date: 2�2-e 1 2 02.€(
�1..pr.1 �--AM Cr_ \ — &g fit.
Print Name and Title of Signed(only if authorized individual signing differs from Legally Responsible Person):
*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 8,Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section 8,Item(6)of the NCG010000 permit.

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CMH HOMES,INC.
WRITTEN CORPORATE CONSENT
Be it known that Larry Carter,Assistant Secretary of CMH Homes, Inc.,having been duly
authorized and empowered by the Board of Directors does hereby designate that Jonathan Lane
Harrell,General Manager of CMH Homes,Inc.DBA Clayton Homes#68,is authorized and
empowered to sign documents related to transactions of the certain real estate located at TBD
Boomer Road,Parcel 0302995,Boomer,NC 28606.General Manager is not authorized to enter
into any Guarantee Agreement or any other contract that would require CMH Homes Inc.to
assume responsibility for any loan balances or payments owed by a consumer if they default on
their home loan with their lender.
I hereby certify that I am the duly qualified Assistant Secretary of the aforesaid Corporation and
that I am authorized to make the aforementioned designation.
Dated tl is 1 sth day of February 2024.
STATE OF TENNESSEE
COUNTY OF BLOUNT
The 15th day of February 2024 personally came before me,Brett Murr a Notary Public for the
said County, and Larry Carter who being by me duly sworn,says that he is Assistant Secretary of
CMH Homes,Inc., a corporation,and that said writing was signed and sealed by him on behalf
of said corporation by its authority duly given.
Witness my hand and official seal,this the l 5th day of February 2024.
-Eat -1/Z-
Notary Public
���;t:,,,.;.., .
•
��.�`N My commission expires: 05/02/2026
4cti.• STATE •`•.
OF 1.
TENNESSEE
0068127 NOTARY
PUBLIC/
5000 Clayton Rcacf • Mmryvdle, Teriness,* 37804 • www.clsytanhomes.com • 065-380.3000 • Fax [phone]