HomeMy WebLinkAboutNCC232680_NOT Signed Certification_20240603 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,6t'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.: AUCGO l OOn0
Name of Project: Ho-kr_ck5 104 sec - 5 4 oc'eta.Lo4
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): (.,J1..,-•e_ C-Vv-c,r I' .x c' e a' ccx-,1, LLC.
*Legally Responsible Person (must match eNOT): KGV�v1 rAe4,1:SZe.L IC
*Title of Legally Responsible Person: CFO
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
C) *Signature: Date: V '/7/2-y
* 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.