NCC204619_NOT Signed Certification_20210429

NCG01 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, 61' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: ht cC R-M
Name of Project: L`►he 20ytj Zo-73 �'$,caCe gep
Per NC General Statute 143-215.68(i), any person who knowingly makes any false 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 fine not to exceed ten thousand dollars($10,000).
Under penalty of law, I certify that:
41 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 Organizational Entity: IAZa aCd,6L a0 Po►11_
* Legally Responsible Person:
Title of Legally Responsi Person: {��,,'dn36P� , ��eC�r�C 1��5irii �4'1 .t- SU—b C005 �Cn
Signature: wf/�&(V v ��_ Date: 41 Z-7 7.�
*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, or a manager that is
authorized in accordance with Part IV,Section 8, Item (6)of the NCGO10000 permit.
For more information on signatory requirements,see Part IV,Section 8, Item(6)of the NCGO10000 permit.