NCC200508_NOT Signed Certification_20200210

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 form to the NC DEMLR Storrwater Program at:
Division of Energy,Mineral&Land Resources Stormwater Program
512 N.Salisbury Street,61h Floor
1612 Mail Service Center
Raleigh,NC 27699-1612
rpnaral Pormit( ortifirata of fnt/araoa Irorl Kin •
Name of Project: 1`e5 i' d e V( C-e
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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...shalt 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.
Legaiiy nesponsiaie Organizationai Entity: " Q
* Legally Responsible Person: '�C yt 1/1 T
T itie of Legaiiy nesponsibie Person: 62
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Signature: ��� Date: /0 — Z 00 0
*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 1V,Section B, Item(6)of the NCGO10000 permit.