NCC190904_NOT Signed Certification_20210111

NCGO1 notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the elect runic NOT (Res€ ssion) form.
Then, mail the orlginal farm w the NC D€MLR Storrnwate r Program at:
Division of Energy, Mineral & Land Resources Stormwatef Program
512 N. Salisbury Street, 6`h Floor
1612 Mail Service tenter
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.; i01�0
Marne of Project:
Per NC General Stotute 143-215.68 (l), any person who knowingly rnakes any fotse staterrrent representr7tlort,
or certification in any applicotion, record, report, plain, or other document fried or required to be Moir?roined
under this A rticle or a rule implernen ting this Article ... Ooll be guilty of a Crass 2 mfsderneanor which rnpy
include o fine not to exceed tern thousond doltors (10, ).
Under penalty of law, I certify that;
X I, as an authorized representative,hereby request rescission of coverage under the NPDE
Storrnvwater Permit for the subject facility. I �n? 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: . 11W,
'Legally Responsible Person
Title of Legall
YS€gnature:
Rrinx NamE
fit4+fiPORTANT NOTE. This form most be signed by a responsible corporote officer shot owns or operates [he
construction activity, such as a president, secretory. treosurer, or vice president~, or o manager thot is
authorized in occordonce with Parr tt! section B, item �6) of the NCG010000 perMU6
For more lnforrnati,:;n on sigtlatary requirements, see Part IV, Section 6, ttern (6) of the lUCGOJ0000 permit_