NCC200869_NOT Signed Certification_20210422

NCGO1 N oti ce of Terra i nation (N OT) Ce r#ifi cation Form
Di rectior15:
% completer scan and ulpload to the electron iC NOT [Re5CinbUn] fqrm_
trail the prigi nal form to the NC :DEMLR Stnrmwater Program at:
:)n of Energy, Mineral & Land Resources Stbrmwatl�r Program
N_ S li�LAry Str , gh Floor
1612 Mail Service Cente-r
Raleigh, KC 27699-161.2
Gerierel Permit Gertificate of Coverage ( C) No,:_--
Na me of Project, / l7 - � 1 �r .
Per NC &Errerui Siatate 1 A —215. 6B (i), any person who knowjng1y n7akefts coy foh5eft stoterF ear repre.;ent RK
tW ertrftc,�t,'arr hr 42.111Y +afro:+, record, report, p;arz, or other dowment frked or regwtred to be mornwir,-d
under rW5 Arrk a or 47 rule implemerrti rg this Article. _ _ shall be guilty qf o Class 2 misdemeanatir wd ich m 7y
irw;udle o f nLr rV to exceed t-r? th u wva d dollars (S10, OW).
LI rider pen.3Ity of law, I outily th at!
I, as an auatharizekd repri�sentativer hembyr request rescis.mon o� coverage under the N PDES Stormwater
PI-ermit For the subject facility. I am fampliiar with the inforroation Contained irp this touest, aml to the best
of ins} know)-dge and 1�eliPf, 5vi;h information i5 true, oamplele, and accurate_
LegaIty flie5powiWe Organizational Entity!
*Leg'Ay Resporr.Sible. Pusan:
Tale of Legally Resporrsi We Rerwn_
*Signature;
—71
Print Name arKd Title of Si n d ICY if cruVwbed rrr ivrd c7l 5hning digs from �eguky Persan);
* LUPORTANT NOTE. Y]hr'.s four: must be srgnco-d by a responsible corporoteoffktr that owns or operrofes fhb
consrrva on activity, €uch ps a p +de €eu etar)f trpo5irrer, or viw taresid�errt or o wwrioger thor is
ewthmLtd in uccor 42.ncel with Port TV, Sft-bort g Rffn f6) 0 the NC6020000 permrt_
For more i ftfbrxmotiof? on sfgnotory requirenvom see Part IV, Secrrof? 8, ttern (6) 0 the Jlt 1 permit.