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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.