NCC201760_NOT Signed Certification_20210601

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, marl the original signed form to the NC ❑EMLR Stormwater Program at:
0ivision of E nergy, Mineral & Land Resources Stormwate r Program
512 N. Salisbury Street, 6' Floor
1612 Mail Service Center
Raleigh, NC 276"-1612
AO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40CFR 122.221
General Permit Certificate of Coverage (COC) No.: A"CC G 0
Name of Project: e YO
;,L r' G /- : ?e4t 66N . 4X
,166�.
Per NC General Statute 143.215.6810, any person who knowingly makes any false statement, representotion, Of
certification in any application, record, report, plan, or other documenr filed or required to be maintained under this
Arr+cle or o rule implementing this Arricle . shall be guilty c/o Class 2 misdemeanor which may include o fine nor
to exceed ten thousand dollars JS10, 000).
Under penalty of law, I certify that:
1, as an authorized representative, hereby request rescission of coverage under the NPDES Storm waLet 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: ¢kl q S -Df-H+L'
'Legally Responsible Person: M S ; tii
Title of Legally Responsible Person:
'Signature: _ pate:
Print Name and Title of Signed [only if authorized individual signing differs from Legally Responsible Person)
IMPORTANT NOTE: This farm muss' be signed by a responsible corporate officer that owns or operates the
consrruction ocrivily, such as a president, secretary, treasurer, or vice president, or a monoger that rs authorized sn
accordance with Port IV, Section B. Item 16) of the NCGOI0000 per mrr.
For more information on signato►y requirernirnts, see Parr IV, Section B. Item 16) of the NCGO10000 permit.