NCC201236_NOT Signed Certification_20240306

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fT
NCGOI 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, 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 014141*****0.0616:00414000. OSA
General Permit Certificate of Coverage (COC) No.: NCC201236
Name of Project: Dormie Club - Maintenance Facility
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:
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): Sampson Construction Co., Inc.
*Legally Responsible Person (must match eNOT): Justin Hall
*Title of Legally Responsible Person: Senior Project Manager
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: 3-6-Zi
* 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 8, Item (6)of the NCG010000 permit.
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