NCC190220_NOT Signed Certification_20210303

NCGO1 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 Resources3torn1vvoter Program
512N.Salisbury Street, 6mFloor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate ofCoverage /[OC\PJO.: Al n� Z �p -� 2 69
Name of Project: &
Per WCGeneral Statute 143-215.688lany person who knowingly makes onyfabestatement, representation,
or certification/nany application,necmnd,repnrt,plan\orntherdocunno0tfiledorrequirpdtoban7Ointoined
under this Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may
include oftnenot toexceed ten thousand dollars ($20,000).
Under penaltyoflaw, | certify that:
El |,aoanauthorized representative, hereby request rescission ofcoverage under the NPDE3
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: _
�
*Legally Responsible Person:_
Title of Legally Responsible Person:
Xe-
*Signature:
FBI
� � .�����^
Date: -/ ' ~' =~~'
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
*/&YPORIANTNOTE.This form must besigned bvo responsible corporate officer that owns oroperates the
construction activity, such osn president,secretoqy, treasurer, orvice president, oromanager that /s
authorized inaccordance with Part IV, Section B,Item (6) of the NCGD 0000pennit.
For more information onsignatory requirements, see Part IV, Section B, Item (6)ofthe N[GO000 permit.
y��'�.