NCC190528_NOT Signed Certification_20210702

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electranit NOT (Rescission) form -
Then, mad the original signed farm to the NC DLMLR Stormwater Program at -
Division of Lrnergy, Mineral & land Resources Starmwater Program
S12 N. Salisbury Street, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS OFFN REVIEWED AND APPROVED
THE FORK! YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL[ [40 CFR 12 2.2 2
General Permit Certificate of Coverage (CDC) No.: _; V Ce, ( � 'o .L%;)
Name of Project: �I1� L�:� �� e� � s c � �•� t r � �.•U ��t A�zr� �Or y -1 3
Per NC General Stature 14_1-215-68 (i), any person who knowingly makes any false statement, represenratton, or
rertificarion in any application, record, report, plan, or other dor ument filed rx required to be mormromed under this
Article or a rule implementing this Article .. shall be guilty of a Class 1 misdemeanor which may include a fine not
to Exceed ten thousand dollars ($10,000)-
Ur4er penalty of law. I certify that
1, as an authorized representative, hereby request rescission of coverage under the NPDE5 Stormwater Permit for
the suhiert 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 acru►ate
Legally Responsible Organizational Entity: _ 1�. r k•
'legally Responsible Person. li , [_[+c.•-d 14 t" L__►ct
Title of Legally Responsible P n_ �'t
*Signature
Date: 6 /1 --2' )
Pant Name and Title of Signed {only if authorired individual signing differs from Legally Responsible Person),
' IMPORTANT NOTE: This four, must be s►fined by a responsible corporate officer that owns or operates the
construction activity, such as a prruderrt, secrefury, treasurer, or vice president, or a manager that is authorized in
accordance w►th fort IV, Section B, Item (61 of the NC(;0100 0perm►t-
Far more information on s►ynotory requirements, see Pori )V, Se-ctran Er, Item (6) of the NCG010000 permit.