NCC205469_NOT Signed Certification_20240514

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 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.: NCC205469
Name of Project: FB - Military Working Dog Facility, PN72426
Per NC General Statute 143-215.6B(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:
verage
er the
ES
Permit for
u authorized representative,familiar
w threby request rescission of the information contained in this quest,and to thebestf myrknowledge
the subject facility. I am fame
and belief, such information is true,complete, and accurate.
Fort Bragg Directorate of Public Works
Legally Responsible Organizational Entity(must match eNOT):
Monica Stephenson
*Legally Responsible Person (must match eNOT):
*Title of Legally Responsible Person:
Director
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
Lee Ward, Chief, DPW/Water Management Branch
Date: 05/14/2024
*Signature:
cer that owns or
the
* IMPORTANT NOTE: This form must be signed by a responsible r vice presideorporate nit or a manager that aauthorized in
construction activity,such as a president,secretary, treasurer,
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.