NCC193169_NOT Signed Certification_20210102

NCGD1 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 5tormwater Program at:
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N. Salisbury Street, 6'" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (CDC) No.: ELIL f y--V6� 2__
Name of Project:
5
Per NC General Statute 143-215.68 (i), any person who knowingly makes ony 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
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: Christopher E. Cates
Title of Legally Responsible Perspn: President
Signature:
*IMPORTANT !VOTE., 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 o manager that is
authorized in accordance with Part IV, Section 8, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part l y, Section 8, Item (6) of the NCGO10000 permit.