NCC192775_NOT Signed Certification_20230502

NCGO1 Notice of Term i oon tiV_C 1D Certification corm
Print this form, complete,scan and upload to the electronic NOT(Rescission)form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVDEWEr,AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED M T H AN ORMNAL SIGNA h URE(NOT DIGITAL) [4®CFR 122.22I,
General Permit Certificate of Coverage (COC) No.: tVa i 71
Name of Project: 006-2 0A) La-IS L/( f
Per NC General Statute 143-215.6B(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 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: e40,I'd 1 City hum es 1.LC,.
*Legally Responsible Person: fN O& i orro c1
Title of Legally Responsible, erson: vA/lAav
*Signature: 1
Date: 5-a-d3
Print Name and Title of Signed (only if authorized individual signing differs from Legally Person):Responsible p
*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 (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.