NCC203648_NOT Signed Certification_20210603

NCG01 Notice of Termination (NOT) Certification
Form
Directions: --
Print this form, complete, can and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
— Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST SE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40
General Permit Certificate of Coverage (COC) No cFR 122•22]
Name of Project:
Per NC General Statute 143-215.68 i an
certification in an application, record, reportrson plan�o oothervdocl umenteslan
y pp ' yfalsestatement, representation, or
Article or a rule implementing this Article ...shall be guilty of a Class 2 misdemeanor which May in
fed or required to be maintained under this
to exceed ten thousand dollars ($10,000).
y elude a fine not
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Storm
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. water Permit for
Legally Responsible Organizational Entity: Qs p�4-
*Legally Responsible Person:
Title of Legally Responsible Person:
*Signature:
Print Name an Title 0-kned (only if
* i w -... -
e
batev
: — Z., -- Z l
individual signing differs from Legally Responsible Person):
tv'r-un/HIV► 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 B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG01000 0 permit.