HomeMy WebLinkAboutNCC192080_NOT Signed Certification_20230523 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 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 REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST RE COMPLE.'T P.WITH AN oiRI INAL S( NA1'l!Rt,E OSIOT DIGITAL) [40.CFIZ 122: 2]
General Permit Certificate of Coverage (COC) No.: Nee, 1
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Name of Project: & ci O, \J In
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: _ _cif✓e '�f4O(\ v 1
*Legally Responsible Person: `M 1\efOrN.
Title of Legally Responsible Person: ' ,t,,›,
*Signature: "
Date:°'3 I
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,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.
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