NCC190789_NOT Signed Certification_20210707

IV CGOI Noti a of Terms nati on (NOT) Certificatio n Form
Directions:
Print this form, complete, scan and upload to the electronic NOT {Rescission} form,
Then, mail the vaginas signed form to the NC DEMLR Stormwater Program at;
Divisinn of Energy, Mineral & Land Resources Stormwater Pragrarn
512 N. Salisbury Street, 6"' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED,
THE FORM YOU MAIL MUST BE COMPLETED WIT AN ORIGINAL SIC,NATURE (NOT DIGITAL) [40 CF R 122.221
General Permit Certificate of Coverage (COC) No.,
R -7
Name of Project: �c o i
er
ova LD &'LK
L 0
Per NC G'enerol Storute 143-215.68 (i), any persona who knowingly makes any false staterrrernt, represerntotion, or
certification in any application, retort}, report, pion, or other document filed or required to be maintained under this
Article or a rule Tmplerrn eating this Article. , small be guilty of o Class 2 misdem ea nor which may include a fine not
to exceed tern thousand dollars ($10,000).
Under penalty of Iaw, I certify that;
I, as an authorized representative, hereby request rescission of coverage under the NPC) ES Storrnwater Permit for
the subject facility. l am familiar with the information contained in this request, and to the best of my knu ledge
and belief, such irtforrnation is true, complete, and accurate,
Legally Responsible Organizational Entity: TQ Cu c> A � t -To c
*Legally Responsible Person; .0--S.Ov�' ( 1 _ e _ _—
Title of Legally Responsible Person;
*Signature;
Print Name and Title of Signed {only if authorized individual signing differs firorn Legally Responsible Person};
* IMPORTANT NOTE: This forma 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 I V, Section B, Item () of the NC 010000 permit.
For more informotron on signatory requirements, see Port IV, Section 6, Item (6) of the NCGOIO000 permit.