NCC190064_NOT Signed Certification_20210520

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
00 NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WtTti AN ORIGINAL. SIGNATURE (NOT DIGITAL [40 CFR 12
General Permit Certificate of Coverage (COQ No.: N+
Name of Project: ( `Tv FN 7ZCS 16 LL
Per NC General Statute 143-215.6I3 (i), any person who knowingly makes ony false statement, representatio
certification in any application, record, report, p!'on, or other document filed' or required to be maintained ur
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fi
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 Perr
the subject facility. I am familiar with the information contained in this request, and to the best of my knov
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity: JAAkES P-A4bALX, CaeklC�L
*Legally Responsible Person: NJA46, A�, RAWACL- -A(Z
Title of Legally Responsible Person. lA'
*Signature.
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person)
* 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 author
accordance with Part IV, 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.