NCC201469_NOT Signed Certification_20200414

NC(-.0J— Notice Off'Teraliviati>: n (N$.. f) Ceriifica►:ion Form
Oirf�JJ"�it°s:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Tlien, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6`r' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (CGC) No.. � ,(,. /, 6 1 , ' `1
Name of Project: G.?�6'qy� !�
Per NC General Stotute 143-215.68 (1), any person who knowingly makes any folse 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 riot to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
1 �,f 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 En ity: _3 -WJ L �C—
Legally Responsible Person:
Title of Legally Kos sibl rr-son: f3n//� �/►I (v _ - , f
Signature: _ - - - Date:.-
*IMPORTANT NOTE: This form must he 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 thot 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.