NCC231433_NOT Signed Certification_20240403

NCGOI. Notice of Termination (NOT) Certification Form
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Directions:
Print this form,complete,scan and upload to the electronic NOT(Rescission)form.
Then, mail the oniginalsigned 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 RE COMPLETED WITH AN ORIGINAL SIGNATURE fl.JR€ (NOT DIGITAL) lL.O CFR 122.221
General Permit Certificate of Coverage (COC) No.: NCC231433
Name of Project: Linden Landing,Phase I -Lots 1,4,7&8
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: A&G Residential LLC
*Legally Responsible Person: Tamie Godwin
Title of Legally Responsible Person: Member Manager
*Signature: ( Date: 9. 4
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
*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.