NCC200608_NOT Signed Certification_20210210

NCG01 Notice Of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NC
Then, mail thel original form to the NC DEMLR Stormwatf
Division of Energy, Mineral & Land Resources Stormwa
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.:
Name of Project:
T (Rescission) form.
r Program at:
er Program
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement, represe
or certification in any application, record, report, plan, or other document file I or required to be main
under this Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor whirl
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
10 I, as an authorized representative, hereby request rescission of COVE rage under the NPDES
Stormwater Permit for the subject facility. I am familiar with the information contained in t
request, and to the best of my knowledge and belief, such information is true, complete, an
accurate.
Legally Responsible Organizational Entity: Is 11 i e.
*Legally Responsible Person:
Title of Legally Responsible Person:
*Signature:
e4
Print Name and Title of Signed (only if authorized individual signing differs
* IMPORTANT NOTE: This form must be signed by a responsible corporate offic
construction activity, such as a president, secretary, treasurer, or vice preside
authorized in accordance with Part IV, Section 8, Item (6) of the NCG010000I
For more information on signatoryrequirements, see Part IV, Section 8, Item
tation,
may
o!;r.?h? n,
7
Date: 01 - /O a
n Legally Responsible Person)
rr that owns or operate the
t, or a manager that is
?rmit.
5) of the NCG010000 pe 7mit.