NCC230297_NOT Signed Certification_20240427

NCGO1 tice of Ter in ti • n ( NOT) Certification Form
Mrrecdoros
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 HOOT MAIL THIS FORM UNTIL YOUR HOT REQUEST HAS E EEN REVIEWED AND APPRSVED.
THE FORM VDU MAIL MUST BE COMPLETED br\dITh AM ORIGINAL SIGNATURE(NOT DIGITALI K®CFR 122.24
General Permit Certificate of Coverage (COC) No.: NCC230297
Name of Project: Creedmoor Manor Lot 6 & Lot 11
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): Wagoner Homes, Inc
*Legally Responsible Person (must match eNOT): Chris Wagoner
*Title of Legally Responsible Person: VP
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Z '� Date: 4-27-24
* 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.