NCC233830_NOT Signed Certification_20240605

NCGO1 Notice of Termination (N i►T) Certification Form
Directions:
Print this form, complete,scan and upload to the el-ctronic NOT(Rescission)form.
Then, mail the original signed form to the NC DE LR Stormwater Program at:
Division of Energy, Mineral & Land Resourc-s Stormwater Program
512 N.Salisbury Street,6t Floor
1612 Mail Service Cen er
Raleigh, NC 27699-16 2
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST H S BEEN REVIEWED AND APPROVED.
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General Permit Certificate of Coverage (COC) No.: kJ L 01, 33 '83 'o
Name of Project: �� IA/Oo lr Sec, j a)
Per NC General Statute 143-215.6E(i), any person who knowingly m►kes any false statement,representation, or
certification in any application, record, report,plan, or other docum:nt filed or required to be maintained under this
Article or a rule implementing this Article. . . shall be guilty of a Clas 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 cove age under the NPDES Stormwater Permit for
the subject facility. I am familiar with the information contained in t is request,and to the best of my knowledge
and belief,such information is true,complete, and accurate.
ecc. (4)Legally Responsible Organizational Entity(must match eNOT): v��e Po l
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*Legally Responsible Person (must match eNOT): Qf)U „ 56,
*Title of Legally Responsible Person: Pet Y .e A--
Print Name&Title of Signed if Authorized Individual Differs from Leg.Ily Responsible Person:
*Signature: Date: (Q- Z4`/
* IMPORTANT NOTE: This form must be signed by a responsible corp• ate officer that owns or operates the
construction activity,such as a president,secretary, treasurer, or vice •resident, 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 : Item (6)of the NCG010000 permit.