NCC221328_NOT Signed Certification_20240920

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.: NC,0-22t323
Name of Project: /3 .00,00lce V(.\tia_. LLAN^ a!'
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):'\DS;OO c3J 6oU+t/l L—U1vv` LL1.
*Legally Responsible Person (must match eNOT): Maki Law\e5
*Title of Legally Responsible Person:vice_?Y e 't( u--\ —(�f'�(1Px .).(�MAUI ( (:Dv FO((At �'w h6
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
T 000 eed I Old Lumk)(2)( ?0,-Ak .M( 6(6)('Ar
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*Signature: s Date: / 40/Z(-1
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* 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.