HomeMy WebLinkAboutNCC192592_NOT Signed Certification_20200921NCG01 Notice of Termination (NOT) Certification Form
Directions:
Printthls 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
1.61.2 Mail Service Center
Raleigh, NC 27699-1612
Genera! Permit Certificate of Coverage (CGC) No., _ NCCC{ qy5a 2-
Name of Project: T")o U.. C -�5� .
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:
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:�0'��Cg�Du�
* Legally Responsible Person: C---�e-zY C 2, bo -ms
Title of Legally
—1I� �Zo
Signature:
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activitypuch as a president, secretary, treasurer, or vice president, or a manager that is
authorized h Fdance with Part IV, Section B, item (6) of the NCC010000 permit.
For more information on signatory requirements, see Part 1V, Section B, Item (6) of the NCG010000 permit.