NCC193046_NOT Signed Certification_20210308

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NQT (Rescission) form.
Then, mail the original form to the NC DEMLR 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 (COC) No.: ' -
Name of Project: {
Per NC General Statute 143-215.68 {lj, any person who knowingly makes any 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:
1, 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;,
*Legally Responsible Person: �) (Y � (' (A- V V 0 i 1
Title of Legally Responsible Person: j J
*Signature:
❑ate:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* I'MPOR►ANT NOTE: 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 1V, Section 8, Item (6) of the NCG0I0000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (5) of the NCGO1000o permit.