HomeMy WebLinkAboutNCC190028_NOT Signed Certification_20210517NCG01 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 DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC190028
Name of Project: AAA Ministora e
Per NC General Statute 143-215.6B (i), 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:
❑ I, 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 Entity: AAA_Ministorage
* Legally Responsible Person:
Paul Williams
Title of Legally Responsible Person: owner
Signature:
* IMPORTANT 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 B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.