NCC205486_NOT Signed Certification_20240712

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 Fnergy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
I
DO NOT MAL.THIS FORM UNTIL YOUR NC' REQL'1ST HAS 3EcN REVIEWED AND APPROVED
THE FUI:M YOU MAII. MUST BE COMPLETED WITI+ rC.: ^ttlGINat _'NI!IT!_:?= (NOT DIG)TALI ,40 CFR 12?.2?:
General Permit Certificate of Coverage (COC) No.: NCC205486
Name of Project: Aglow Property
Per NC General Statute I43-215.68(1), any person who knowingly makes any false statement, representotion, or
certification in any application, record, report,plan, or other document filed or required to be maintained under this
Article or o rule implementing this Article . . , shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars (S10,000).
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): David and Patricia Aglow
'Legally Responsible Person (must match eNOT): David and Patricia Aglow
'Title of Legally Responsible Person: Property Owners
Print Name& Title of Signed if Authorized individual Differs from legally Responsible Person
'Signature: 414.14.
Date: o 71 iv1,tv1/
' IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such os a president, secretary, treasurer, or vice president, or o manager that is authorized in
accordance with Port IV, Section 8, (tern(6)of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, item(6)of the NCG010000 permit_