NCC192097_NOT Signed Certification_20230615

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.
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General Permit Certificate of Coverage (COC) No.: NCC192097
Name of Project: Jacksonville Station
Per NC General Statute 143-215.68(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(must match eNOT): City of Jacksonville
*Legally Responsible Person (must match eNOT): Ronald F. Massey
*Title of Legally Responsible Person: Deputy City Manager
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: " Date: �� j
* 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 8, Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section 8, Item(6)of the NCG010000 permit.