NCC191759_NOT Signed Certification_20201117

11MCGO1.Natice of Termination (NOT) Certification Form
Directions:
Printthis form, complete, scan and: upload to the electronic NOT (Rescission) form:.
Then, mail the original form to the NC DEMLR Stormw.ater Program.at-
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury 5treet,.6"' Floor
1612 Mail Service Center
Raleigh, N.0 2.7699-1612
General Permit Certificate of Coverage (COC) No.:
Name of Project:
rICC1glT59
�e Mt(4'� cal 0gice
Per NC General Statute 143-215, 6B (i), ,cony 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, sho11 be.guilty of a C1ass2 m sdemeanor which may
include ,a fine not to exceed ten thousand dollars ($30,O0O).
Under penalty of Iaw,. i certify that:
I, as. an authorized representative, hereby request.rescission of coverage under the NPDES
Storm.water 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.
Legaily Responsible Organizational Pntity: L7�f✓Gi
* Legally Responsible Person: 1 I
Title. of Legally Ressible Peyn:��
Signature;
I/�arQqles—
Pate: rt 1 ! 2
* 1MPORTANT.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, ltem (6) of the NCGO10000 permit..
Far more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.