HomeMy WebLinkAboutNCC231235_NOT Signed Certification_20240513 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'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.: 2_LI L L1214 )IT' f M Li - 20 2. 00
Name of Project: ( I VQ `l 1 lam- N-M //)• L
Per NC General Statute 143-215.66(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(510,000).
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: i
*Legally Responsible Person: 1 �[�1��� "\ P\S rt nn j� 1 N
Title of Legally Responsible Person: `J ly 1�
*Signature: Date: Oc 1 O' I7 02-1
Print Name and Titie of Signed(only if authorized 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 B,Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B,Item(6)of the NCG010000 permit.