NCC231006_NOT Signed Certification_20240226

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 12212]
General Permit Certificate of Coverage (COC) No.: "' 'i ., )3) d t'? ,
Name of Project: jYrt iit bir1r 61r44 Le
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. l 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: r tUIn wpm, e1, /iv' i `` C.
*Legally Responsible Person: M/b''e A/4Y ,A
Title of Legally Responsible Person: NI eh% b v
*Signature: "1,00 y__4Z iC
Date: 2
__2j
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 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.