HomeMy WebLinkAboutNCC190703_NOT Signed Certification_20201221NCG01 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 ❑EMLR 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.: �' G (a D 0
N!a rne of Proiect:
& &rae- VVCa i C-d c� U.U,
J-!61
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, represen tation,
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 misdemea,7or which may
inciude a fine not to exceed ten thousand dollars ($10,000).
Undar penalty of law, I certify that:
1, 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: IW o\jA,/y+ 4e44-�
"Legally Responsible Person: MA6-i %1 n t - _._... --
Title of Legally Responsible Person: y6u, rcl; OLUI*. I .
`Signature: _ z� - Date:
P�Int Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
' IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the
consrruction 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.