2024-111-E-Planning Dept-Christopher Sandt -need Bonnie’s hard signature on an NCDEQ notice of termination not form so that we may formally close out the Lake Orange

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NCG01 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.: ___________________________________ Name of Project: ______________________________________________________________ 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: 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):_________________________________________ *Legally Responsible Person (must match eNOT):_____________________________________________________ *Title of Legally Responsible Person:_______________________________________________________________ Print Name & Title of Signed if Authorized Individual 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. *Signature: _____________________________________________________________Date: _______________ NCC220409 Lake Orange CIP - Project 1 - Erosion Control Barrier Replacement (BASE BID ONLY Orange County, North Carolina Bonnie Hammersley County Manager DocuSign Envelope ID: 45F63519-E597-49A4-A85A-BE797784EB5F 2/19/2024