NCC190815_NOT Signed Certification_20210709

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the origins/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
DO NOT MAIL THIS FORM UNTiL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
General Permit Certificate of Coverage (COC) No.:
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Name of Project: _-- %tt Sntc C
Per NC General Statute 143 215,68 A), any person whb knowingly makes an
certlftcatlon in any application, record, report, plan, or other document filed or required o be mafntainedyfalse statement, tunder this
Article or d rule implementing this Article... Shall be guilty of a Class 2 misdemeanor which may include a ne r t s
to exceed ten thousand dollars ($10,ODp1• t
Under penalty of law, I certify that: .
1, 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 knowle
and belief, such information is true, complete, and. accurate. age
Legally Responsible Organizational Entity:
*Legally Responsible Person: CIA \ a n .. „ 1
Title of Legally
*Signature:
Print
of Signed (only !f authorized Individual signing differsfrom Legally Responsible person):
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/MPORTANT 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,
accordance with Part !V, Section 8, Item (6) of the NCG010000 permitor a manager that is authorized in.
For more Information on signatory requirements, see Part iv, Section B, item (6) of the NCGol0000 permit.
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