NCC231315_NOT Signed Certification_20240709

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 122.22]
General Permit Certificate of Coverage (COC) No.: 1C.,C,'31-5VJ
Name of Project: 1' IICV\UQ--S R\ -�
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. C
Legally Responsible Organizational Entity(must matchat eNOT): �Q�\ ,,(fie-S - �JV 1��L.
*Legally Responsible Person (must match eNOT): IJD.(���\ NI t\l>r1
*Title of Legally Responsible Person: 1 ' ta(19-Qef
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: ) Date: / r00.)L!
*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.