NCC192626_NOT Signed Certification_20211104

NCG01 Notice of Termination (NOT) Certification Form
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEMLR Storrnwater Program at:
Division ofEnergy, Mineral & Land Resources StonnvvaterProgram
S120.Salisbury Street, 6wFloor
1G1ZMail Service Center
Raleigh, NC 27699-1612
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N8�lgOfP Project: � ^
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfolse statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Ardcle 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 oflaw, | certify that:
1, a an authorized representative, hereby request rescission of coverage under the NPDES Stonnw/aterPermit for
the subject facility, |amfamiliar with the information contained inthis request, and tothe best ofnoyknowledge
and belief, such information is true, complete, and accurate.
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Legally Responsible Organizational Entity: NVIt
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UyResponsible Person:
Title ofLegally Responsible Person: C44
*Signature:
e:
Print Name and Title of Signed (onlyif authorized individual signing differsfrom Legally Responsible Person):
* ORTANT NOTE: Thisfornimmt be signed byoresponsible corporate officer that owns moperates the
con�tructionactivity, such usopresident, secretary, treasurer, orvice president,oromanager that isauthorized /n
accordance with Part IV, Section B,Item (6) of the NOGO10000permit.
For more information onsignatory requirements, see Part IV, Section B, Item (6) of theNCG010000 perm