NCC230568_NOT Signed Certification_20231206

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, 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 122.22J
General Permit Certificate of Coverage (COC) No.: AdCCa 30 (00
Name of Project: AVO4 / ✓1
Per NC General Statute 143-215.6E(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.
TDLegally Responsible Organizational Entity(must match eNOT): . „'`-
*Legally Responsible Person (must match eNOT): 6/1 �0. + V1,t-�
*Title of Legally Responsible Person: U,'Ce pire i d 0
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
-7)Ov /771 4 rkeV1 A55iS-ta�..� e 7
*Signature: I L Date:
/2-/6/02 3
* 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 B, Item(6)of the NCG010000 permit.