NCC192441_NOT Signed Certification_20210825

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 5tormwater Program at:
❑ivision of Energy, Mineral & Land Resources 5tormwater Program
512 N. Sal isbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS 8EEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL)140 CFR 122.22)
General Permit Certificate of Coverage {CCQ No.: 9
Name of Project: 5oulrtk kar I s Af\s F-te 15f0lf;0 PJ
Per NC Generol Statute 143-2I5.66 (i), 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 yaw, i certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subject facility. I an^ 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: V)Astc Gqn AtJ io pi 5 Y� Nor-h\ �06 LAC( -Try t,,
*Legally Responsible Person: R6 W01(
Title of Legally Respons
*Signature:
rson: l�), Y+S: D ri U; a `)f Z5 I q
�w
Date: Vy ZZ6/'qj
Print Name and Title of Signed (only if authorized individual signing differs from Legaliy 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, secretory, treasurer, or vice president, or a manager that is authorized in
accordance with Part IV, Section 8, Item (6) of the NCG01 0000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCG010000 permit.