HomeMy WebLinkAboutNCC192486_NOT Signed Certification_20210102NCG01 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 5tormwater 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
1
General Permit Certificate of Coverage (CGC) No.: L-127c'-s_ �-6
Name of Project:
D
Per NC General Statute 143-215.0 (i), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document)rled 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 aline 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
5tormwater 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: Cates Building Inc
* Legally Responsible Person:
Title of Legally Responsible P
Signature:
Christopher E. Cates
President
e: j x�
* 1MPORTANTNOTE. 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 NCG010000 permit.