NCC233405_NOT Signed Certification_20241024

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form,r omplete,scan and upload to the electronic NOT(Rescission)form.
then,mall the original rlgned lorm to the NC DEMLR Stormwater Program at:
Divinlnn of Lnergy,Mineral&Land Resources Stormwater Program
S I 7 N.Salisbury Street,6th Floor
1612 Mail Service Center
Raleigh,NC 27699-1612
DO NO1 MAII !III%I OM UN!IL YOUR NO) REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST III COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL)(40 CFR 171.271
General Permit Certificate of Coverage (COC) No.: NIC.,C...Lliby o
Name of Project: Tot tea ( ,es j�- 1NI tU C15'Fot N
Per NC General Statute 143.215.6E(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): ,tOXN&O 1 cofftbA. ' A.A4U
"Legally Responsible Person(must match eNOT): C., or I drCAS
'Title of Legally Responsible Person: Mar1.aQ tY
Print Name&Title of Signed If Authorized individual Differs from Legally Responsible Person:
"Signature: Date: lOIZN(2'I
*IMPORTANT NOTE: This form ust 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.