NCC201077_NOT Signed Certification_20210322

NCG03 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, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699.1612
General Permit Certificate of Coverage (COC) No.: Am a a 10
Name of Project:
Per NC General Statute 143-215, 69 (I), any person who knowingly makes any fulse 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 flue 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.
Legally Responsible Organisational Entity: _I_,t
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*Legally Responsible Person:
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Title of Legally Responsible Person: CE-?—)
*Signature:
Print Name
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,,,,..ponslble Person}:
" 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, Ora manager that is
authorized In accordance with Part IV, Section R, Item (6) of the N03010000 permit,
For more information on signatory requirements, see Part IV, Section 13, Item (6) of the NCG010000 permit.