NCC231084_NOT Signed Certification_20240506

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.: 'cQQ i31 0 A
Name of Project: (MOI 'lk 6' 0SSI(j - phase one. - lO S Z( 121 17:112R
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. 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. Io
Legally Responsible Organizational Entity(must match eNOT): J fl S t ��(�� Q S�a iL S tY ►nvt�S `i IC
*Legally Responsible Person(must match eNOT): 0 Y t Cl Yl 'A)Cl t
*Title of Legally Responsible Person: pV f S (AMA-
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
U.0.1A16. V)4144.
*Signature: Date: SW 7 aet
*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.