NCC231280_NOT Signed Certification_20230802

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 BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: Al Cc a8O
Name of Project: H anKS Lak 13.)%tise 2.
Per NC General Statute 143-215.66(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 aline 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): C'cy1Cil I (c( '[ i 'S
*Legally Responsible Person(must match eNOT): '3ur,p5 )el'h45e1,
*Title of Legally Responsible Person: flcav“-P/
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Sign
ature:ature: Date: o�3
*IMPORTANT OTE: 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.