NCC191166_NOT Signed Certification_20200110

CG 1 Notice of Termination 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 Stormwater Program at:
Division of Energy, Mineral &Land Resources Stormwater Program
512 N. Salisbury Street,6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCJC
Name of Project:
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:
1,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.
Legaffy Responsible Organizational Entity: &—N t AQ&-5 , -Y-)QNQ-1PW Y-,
* Legally Responsible Person:
Title of Legally Responsible Person: .Q
Signature: Date: I I 11p 8 120
*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 1V,Section B, Item(6)of the NCGO10000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCGO10000 permit.