NCC230374_NOT Signed Certification_20240229

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; NCGO1 Notice of Termination (NOT) Certification Form
ItDirections:
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:
Ir
' Division of Energy, Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,6th Floor
f 1612 Mail Service Center
f Raleigh,NC 27699-1612
;I IDO 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.: N CC- a3 02,1 "[
Name of Project: V;e_6j r 1 geqfb + CKLl( C h
Per NC General Statute 143-215.68(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(must match eNOT): \fel-CA-Or ul eict,11)t-`sf Ch ci eh, DC Den
*Legally Responsible Person (must match eNOT): G�C...)S or-, O0.. its...t��
*Title of Legally Responsible Person: 1 T' ..4_3t.Vt(
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
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P*Signature: Date: g'a9- wi,
*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. I
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.
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