NCC230420_NOT Signed Certification_20240506

NCG01 Notice of
Termination (NOT)
Certification Form
Print this form Directions:
Then, complete,scan and upload to
mail the on the electronic NOT
9ma/signed form to the
NC DEMLR Stor (Rescission) form Division of Energy Mineral rr►water Program at:
& Land Resources Stormwater Program
512 N.Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699_1612
DO NOT MAIL THIS FORM UNTIL YOU
THE FORM YOU R NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) MO CFR izzzzj
Certificate of Coverage (COC) No.: NCC230420
Permit
Name of Project: GUERRANT SPRINGS ROAD
certiPer NC General Statute 143-215.68 Gen in an (0, any person who knowingly makes any false statement,representation,or
fication applirntion, 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
to exceed ten thousand dollars($10,000). misdemeanor which may include a fine not
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.

Lc5aiiy 1\e UFrslole urganlzatlonal entity(must match eNOT): uHly KIVtK VVHI LK
*Legally Responsible Person (must match eNOT): MIKE LEMONS
*Title of Legally Responsible Person: SUPERVISOR
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: � '�'"`"� Date: 6 \
* 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.