HomeMy WebLinkAboutNCC231520_NOT Signed Certification_20240514 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 FC NF 1 OU MAt1[.TANSTAE c4NIPl.E'TED WITH AN-ORIGINAL SI TU (NOT DIGIT DIGITA13 140 CFR'LZ2.221
General Permit Certificate of Coverage (COC) No.: N cr a31 5aD
Name of Project: RC1L4D Saa ENNA..
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. '„
Legally Responsible Organizational Entity(must match eNOT): S��,,,� t U`nbn-I Q- Yle
*Legally Responsible Person (must match eNOT): 5i Qinr1OY) 1 1QX
*Title of Legally Responsible Person: Q 1.DY D r—
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: QC1 I ay
* !MPORTA E: 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 B, Item(6)of the NCG010000 permit.
•