NCC204944_NOT Signed Certification_20241110

NC+GO1 Notice of Termination (NOT) Certification For
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 I� ��� FORM M UNTIL YOUR
OCR NOT REQUEST
EQ = T HAS BEEN
REVIEWED AND APPROVED
THE FORM YOU MAIL MUST ern COMPLETED WITH AN ORIGINAL SIGNATURE(NOT D;Y p) (4 C f 22
General Permit Certificate of Coverage (COC) No.: NCC 204944
Name of Project: 2228 Inwood Landing Ct.
Per NC General Statute 143-215.6E(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): Jokisch Construction
*Legally Responsible Person (must match eNOT): Chris Jokisch
*Title of Legally Responsible Person: President
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Ci Date: 11/10/24
* 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 8, Item (6) of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.