NCC190494_NOT Signed Certification_20191112

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 form to the NC DEMLR 5tormwater Program at.
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N. Salisbury Street, 6" Floor
1612 Mail Service tenter
Raleigh, NC 27699-1612
Generai Permit Certificate of Coverage SCGCj No.: N C c- t 9 0'-0
Name of Project: 2 antX';'r L-C�-�e cln
Per NC General Stature 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 maintoined
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 dollors ($10,000).
Under alty of law, 4 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: C}�i� �c S� l�� F;: �P , LLC—
tom"
Legally Responsible Person: i�A
Title of Legally Responsible Person:
Signature:
Date: { tr r
' 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 fV, Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (61 of the NCG010000 permit.