NCC223877_NOT Signed Certification_20240927

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOT(Rescission) `orm.
Then,mail the original signed form to the NC DFMLR Stormwater Program at:
Division of Energy. Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,6'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 DIQTAL) [40 CFR 122.22j
General Permit Certificate of Coverage (COC) No.: CC Q '`a �S 77
Name of Project: , .1/4.)e/(kflc rd
Per NC General Statute 143-213.68(i), any person who knowingly makes any false statement,representation, or
certification in any application, record,repot 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): C7b�Cl �S(1S iRc 1Cn C
•Legally Responsible Person (must match eNOT): , X\C1.11k`k I 17
*Title of Legally Responsible Person: OL (\P+ 1r 11).rc c -?I
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
`Signature: {Cam) - �� [f'� DatePf
• IMPORTANT NOTE: This form must be signed by o 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 N,Section 8, Item(6)of the NCG010000 permit_
Far more information on signatory requirements,see Part IV,Section B, item(6)of the NCG010000 permit_