HomeMy WebLinkAboutNCC191193_NOT Signed Certification_20200116 C1 Notice of Termination T 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'h Floor
1612 Mail Service Center
Raleigh,NC 27699-1612
General Permit Certificate of Coverage (COC) No.: �U— qH s
Name of Project: Z(UDKAY-<XA5 %l9116MX\8
Per NC General Stature 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 enalty of law,I certify that:
7 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:L11i oes5 ���1IQ�lVH�, Q �, Inc—
Legally Responsible Person: Wo+�un G a a
L V i o
Rv-E�IasmETitle of Legally Responsible Person:
Signature: Date: fW101 30a
*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 NCGO10000 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NCGO10000 permit.