NCC233721_NOT Signed Certification_20240604

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 122.221
General Permit Certificate of Coverage (COC) No.: N cC a,33 121
Name of Project: CLccALiL_- et?S LX5I 10
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($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subject facility. I am familiar with the information contained in this request,and to the best of my knowledge
and belief,such information is true, complete, and accurate.
Legally Responsible Organizational Entity(must match eNOT):& ,6 ,N,. `1t4' pc' C,O,ArniA(-r ot C.•
*Legally Responsible Person (must match eNOT): ,cAn ar/A LA t a,M.$
*Title of Legally Responsible Person: U.k.)INP.pr I MLA, !i✓
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
* g7120..AVIA-----. //--- ---
Signature: i ' Date: tP
* 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 6, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.