NCC230666_NOT Signed Certification_20240312

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
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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
L___ 512 N.Salisbury Street,69'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 122.221
General Permit Certificate of Coverage (COC) No.: N C-C- a 3 O G 0 6
Name of Project: C �a. Q1� �t P_. — Lod- 14 19
Per NC General Statute 143-215.6B(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): C� CGlAA 3-0kr '` t ti)
'Legally Responsible Person(must match eNOT): C t 0 re_ 0-"a -37t kn Kv A
`Title of Legally Responsible Person: L o L A
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
(-\\, (/)
*Signate: z Date: 3 z Z 2
* IMPORT T NOTE: This for 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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