NCC193214_NOT Signed Certification_20210721

NCGA1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete,scan and upload to the electronic NOT(Rescission)form.
Then, mail the original signedform to the NC DEMLR Stormwater Program at:
Division of Energy, Minera.l.& Land Resources Stormwater Program
512 N.Salisbury Street, 6`h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE' ST BE CM
Genera! Permit Certificate of Coverage (COC) No,: 9CL1 QS 2J 1
Name of Project: pC Siru�ie fQmticl Ph Z lhdiyi Lkal L2t �Gh
Per NC General Statute 143-215.6B(1), 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:_
I'R' alf-
*Legally Responsible Person: Jon_ Hack
Title of Legally Responsible Person: C
*Signature: Date:
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 authorized in
accordance with Part IV,Section B, Item (b)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NC6010000 permit.