NCC232626_NOT Signed Certification_20240307

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,6`h 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.: N C C 1..32 .'2.'G'
Name of Project: -ll;'(\t 1nOW, n vat i SICh(!n Thfci? - I o C 2 Z I ZS i(f:c
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. pe ,nn nil �, 1Y y4 ( vt
Legally Responsible Organizational Entity(must match eNOT):fin I�lt���� 5 �� I;l t�� W�t�ll J��C�S (I l L
*Legally Responsible Person(must match eNOT): V-2fk V{
*Title of Legally Responsible Person: Vtcl(11.,M
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
046010t
*Signature: W^ Date: 31 1 ( 7 7'1
*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 8, Item(6)of the NCG010000 permit.
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