NCC203443_NOT Signed Certification_20210324

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upldad to the electronic NOT IRescission) 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
NC 27699-1612
General Permit Certificate of Coveraage (COC) No.: � CC 70 5 k
Name of Project: VrQ 4OL at V
Per NC General Statute 143-215.68 (iJ, any person who knowingly makes any false statement representation,
or certification in any application, record, report plan, or other documentfiled 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 jrne not to exceed ten thousand dollars ($10,000).
Under enalty 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 Organiz
* Legally Responsible Person:
Title of Legally Responsible
Signature:
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction actJvity, such as a president secretary, treasurer, or vice president or a manager that 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 NCGO10000 permit.