NCC191820_NOT Signed Certification_20210113

NCG01 Notice of Termination (NOT) Certification Form
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original form to the NC DEMLR Stormwater Program at-,
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, Wh Floor
Wagub"am
General Permit Certificate of Coverage (COC) No.: A1C1' I q I RZO
Name of Project: 84 r ro tv
Per NC General Statute 143215.68 (j), any person who knowingly makes arty, se statement, representation,
Or certification in any application, record, report plan, or other documentfiled 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.
LK 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 Entlt)r.
*Legally Responsible Person:
Title of Legally
*Signature.
Person:
Print Name and Title of Signed (only If authorized individual signing differs from Legally Responsible Person}:
IMPORTAAMNOTE.- 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 8, Item (6) of the NCGO10OW permit.
For more Information on signatory requirements, see Part IV Section 8, Item (6) of the NCG010000 permit.