HomeMy WebLinkAboutNCC230566_NOT Signed Certification_20240306 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.: !V 'C L 2-3 U 5 4'
Name of Project: 11+5 < ) , 3p -Thy P)mnvrs at Vyn gir56
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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,e,f and accurate.
Legally Responsible Organizational Entity: f�V K 7r113; rk Knr) �d
*Legally Responsible Person: r d I
Title of Legal Responsible e 'mJ Z C iii th-t
*Signature: Date: 3167Igo)*
Print Name and Title of Signed (only if au orized 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 8, Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section 8, Item(6)of the NCG010000 permit.
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