HomeMy WebLinkAboutNCC190792_NOT Signed Certification_20201012NCG01 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 Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6`^ Floor
1612 Mail Service Center
NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC190792
Name of Project: Mount Olive Pickle Company Inc. -truck staeine area
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:
rd/ 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: _ Mount Olive Pickle Company Inc
* Legally Responsible Person: Richard D. Bowen
Title of Legally Responsible Person: Executive VP/CFO
/;Gy�r Signature: y�i6/.Uhn/�11hl_ '\ Date:
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* 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.