NCC192774_NOT Signed Certification_20230105

NCGOZ Notice of Termination (NOT) Certification Farm
Directions:
tint this form, complete, scan and upload to the electronic NOT (Rescission) form.
V11Then, mail the originaisigned 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 THI5 FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED,
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.: 0_ ;F'C
Name of Project:
ter Nc General Statute 14.3-115.68 (i), any person who knowingly makes any false statement representation, orTV certification in any application, record, report pion, or other document flied 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 o fine not
to exceed ten thousand dollars (S1Q000).
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 knowledge
and belief, such information is true, complette, and accurate.
Legally Responsible Organizational Entity: y T �
*Legally Responsible Person`Tn, 3„n.P�,n [ -��i v- e'Ar
Title of Legally Respgr�bs le Person:
*Signature:
I a, /,—;2 � 0 0), es'.
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, secretory, treasurer, or vice president, or a manager that is authorized in
accordance with Port IV, Section B, Item (6) of the NCGOIOOL}o permit,
For more information on signatory requirements, see Port tv,, Section 6, item (6) of the NCGOIOOOO permit,