NCC201920_NOT Signed Certification_20210506

N C 01 Notice of Termination ( NOT) Certification Form
Di rections:
1i:5 form: oomplete, scan and upload to the eleManic NOT �R.esci5s;
[ten, ma it the original farras to the K DEM LR Swrmwater proFrani
Division of Energy, Mlirreral & Land Resoume5 $tormwater Progm
51.2 N_ Salisbury Street, 6"' Flnyr
161-2 Mail Service CentCw
Raleigh, KC 22699-i612
General PeTMIt C-ertificabe of Coverage (COC) fro_; C_ 1'R 20_
Narne of Project: l C If- ` '-n -e s �— _
Jar fJC Gerwroi Stat 14 3-215.&B N, any person w-ho knowingly makes any faSe ; wterrwrrf, rie�'ese�t�+on,
(w rertr Lion in any aWicaLron, rftord, report Flory, or other vinent fried or rc ired to be maintained
gnaLgr rhm AxTitke yr a r7.hte rmpderrrenrirr�r this Article . - - shall be!uti?ty of a Cass 2 rrrrsdemean r which ffloy
include u frne fvt to emwEd tern thOu- Md dotiar� 00,000-
Under penalty of I,)vw, I certify that:
I, as an authorized representative, hereby eeq west re5ci:�sion of c:oY& ge under the NpDES StormwaLer
Permit for the subject facility. I am familiar with the information corgi ned in this request, and to the hest
of my knmOcL lge -and be4pf, such inform-akiar` is true, compWie, and accurate.
Legally: Responsible DrganizMional 1=ntity_
"Legal tyr Responsible person
Title of Legally Responsible Person-_
*Signawr.e; _ � + � nate:
Print Name and Ed Of Signed {Only if auttwized individual si96ng dif fiery from Le;aik Pesoonsibh' PFrsanf :
= MMRTANTIVOFE: TfrisJbrm must be signed by47 respanmrbk corporate officer that -owns cr opemtts the
cow.r6iGtiorr acrmzy, suctr as 0 pT5idenr secretary, bvvsurerr. 1xr pie Fresnden� or a Murwqer that es
authorized ir? occorkdan+ce with Port W Senior A item W of the NC6030MO PeMlLfT-
Formore informarian 4M sr'grwrory req-uwements, ste Perrx!V, .Section 6, hoer:: (6) of the N4 66010 =it_