NCC224103_NOT Signed Certification_20230712

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, 6`1 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 BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: fLC 224103
milno r .tbdtvi sia n o- T kcs) aYn 0 2 cxnd
Name of Project: (tc.omv):rat-Vvn of 'Ot G
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: Re n c rn�yrl St0 L,c1 RA C&l Q.54( ,1-2 c,-f—vvt cQS Inc •
*Legally Responsible Person: n Ok,rk
Title of Legally Responsiblei Person: pce ��ca_eivA-t
*Signature: Jctliat, Date: 1i:2,23
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 1V,Section B,Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section 6, Item (6)of the NCG010000 permit.