NCC232277_NOT Signed Certification_20230912

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) farm.
Then, mail the prrginol signed farm to the NC 1)EMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
D❑ NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS 8EFN 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.: l {OC a3 a
Name of Project: Gn S
Per NC General Statute I43-2I5.50 (i), any person who knowingiy makes any false statement representation, or
certification in any application, record, report, pion, 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 fare not
to exceed ten thousapd dollars ($I0,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDE5 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 ar.curatP..
Legally Responsible Organizational Entity {must match eNOT): wtc __ CaE} ZIPrs4ci'c,, yro--
•Legally Responsible Person {must matrh eNOT}: 4;�r CiQ t f
`Title of Legally Responsibie Person: tx)fr� man 4
Print Name & Title of Signed if Authorized Individual Differs from Legally Responsible Person:
'Signature: Date: q-f.2-'A3
* IMPORTANT NOTE: This farm must be signed by a responsible corporate officer that owns or operates the
construction activity, .s,irh as a president secretory, treasurer, or vice president, or a manager that is authorized in
accordance with Part 1V, Section 8, item (6) of the NCG010000 permit.
For more infnrmntinn on signatory requirements, see Part IV, Section B, ltern (6) of the NC6010000 permit.