NCC203658_NOT Signed Certification_20210120

NCCO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, Scan and upload to the electronic NOT (Re;ciaiort`, form.
Then, mail the original form to the NC DZ=MiR Stormwater Program at:
Derision of Energy, Minerai & Land Resourtps Stormwater Program
512 N. Salisbury Street b h Floor
1612 Mail Service Center
Raleigh, NC 27694-1612
General Permit Certificate of Coverage (COC) No.: �j C-c 3 L 58
Name of Project: ;Zc
Per NC General Statute 143-2 5_68 (i), arty person who knowingly makes arty faise .rtutemerrt; represcnta-Uan,
or Certification in any application, record, repor& plan, or other document filed or required to be rnaintairred
under dhis Article or o rule implementing this Article . _ . $hull be guilty of a Class 2 misdemeanor which may
include, a fate not to exceed Len thousand dalfars ($1 Q 000),
Under penalty of law, l certify that,
AI, as an authorized representative, heraby request rescission of coverage under the NPf)ES
Stormwater Permit tor the subject facility. € am familiar with the information contained in this
request, and to the best of my knowledge and belief, such information is tnle, corrip€rate and
accurate_
Legally Responsible Organizational Entity: U w r 1: s"1513�
*Legally Responsible Person: NkO i%ti N
Title of Legally Respo e Person,:
'Signature:
date: L
_9=q
Print Name and Ttle of Sigrwd {ordyif authorized tr]dividuaf signing difers frpm Le-qally Re,5porrsible PPrson}_
• IA4POATAIVT NOTE. ''his form mus< be signed by a re5nans;ble Corporate 0 Cer that o�+ms or r�erdtes the
rnnstruetran a vrty, such as a presidenw secretary, t,"eusuref or vice preSidellt< or a Manager that is
Authorized in accordance Wth Part jv, .Section 8, item (6) of the NCW10000 permlL
for more injf grmatian on sigautnry requiremen Es, see Pori IV, Section 0, item (6)Of the NCGOID O Permit_