HomeMy WebLinkAboutNCC191238_NOT Signed Certification_20201214NCGO1 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 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
General Permit Certificate of Coverage (COC) No.: NCC191238
Name of Project: Meherrin Agricultural & Chemical Company
Per NC General Statute 143-215.6B (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:
IN 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: Meherrin Agricultural & Chemical Company
* Legally Responsible Person: Buster Andrews
Title of Leeally Responsible Perso
Signature:
December 14, 2020
* 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 Port IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.