NCC222903_NOT Signed Certification_20240923

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.: Or,c_ 222_9 b 3
Name of Project: oek 5 kialit_ -7-P1,161,5t1.
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): M.Y.s T 1. LLC
*Legally Responsible Person (must match eNOT): -S-De r-Po it£
*Title of Legally Responsible Person: Vice, stAent
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: % -1-Al::>; 1:(/ Date: SEPT' II, 2O2'f
*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.