NCC191173_NOT Supporting Documents_20220708

NCG01 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 DE;MLR Starmwater Program at:
Division of Energy, Mineral & Land Resources Storm%vater Program
512 N. Salisbury Street, 6"' Floor
1612 Mail Service Center
Raleigh, VC 27G99-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAiL iv1UST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (+id CFR 122-221
General Permit Certificate of Coverage (COC) No.: NCC191173
Name of Project: Tnangle Stop - Penrose, NC
Per tVC General Statute 143-2IS.69 (i), any person who knowingly makes any fafse statement, representation, or
certification in any application,record, report, plan, or otherdocument 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 ($I0,000).
Lander penalty of taw, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the ?1PDES Storm,/rater Permit for
the subject facility. I am familiar with the information contained in this request, and to the best of my kno•adedge
and belief• such information is true, complete, and accurate.
Legally Responsible Organizational Entity: J.H. Reaben Oil & Supply Co., Inc.
'Legally Responsible Person: Hall Waddell
Title of Legally Re<_ponsi P r on: Sq�✓ 'j
'SignaturDate:
Print Name and Title of Signed (only if authorized indMduaf signing differs from Legally Responsible Person):
IMPORTANT NOTE: This form must be signed by a resco,^,sible corporate officer that owns cr 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 (Gj of the NCGOIC0510 permit.
For more information on signatory requirements, see Part )V, Section B, Item (6) of the NCG010500 permit.