NCC201482_NOT Signed Certification_20210628

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NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this firm, complete, scan and upload to the electronic NOT (Rescission) form.
Then, maid the original signed form to the N C DEMLR Sto rmwate r Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Streetl 61� Floor
1612 Mail Serv*1
ce Center
Raleigh, NC 27699-1612
DO NOT MAIf. THIS FORM UNTIL YOUR 'NOT REQUEST HAS BEAN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE SNOT flEGiTAi.) t40 CFR 122.22]
General Permit Certificate of Coverage (COC) Noafi0
Name of Project:
Nc(:f
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Per NC Genera! Statute 143-215.6B (i)., any person who k , nowingly makes any false statement, representation,, or
certification in any application.,- record,, report plan., or other documentfiled or required to be maintained under this
Artirle or a rule implem en ting this Article ... shall be guilty of a Class 2 misdemeanor which may Include ❑ fin e not
to exceed den thousand dollars ($10., 000).
Under penalty of law, ! certify that:
1, as are authorized representative, hereby request rescission of coverage under the NPDES Stormwater Kermit 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:
*Legally Responsible Person: P7
S
Title of Legally Responsible Person:
*Signature: 9
Date: �—�.
Print Name and Title of Signed (only if authorized individual signing differsfrom Legally Responsible Person:
40
* IMPORTANT NOTE;* Thrsform must be signed by a responsible corporate officer that owns or operates the
construction activ�ry, such as a president, secretory, �re�surer, or v��e presrdenr, or a mcrnoger that is authorized in
accordance with Part !V, Section B,, !tern (6) of the NCGO10000 permit.
For more informotion on signatory requirements, see Part IV, Section B, Item ( of the NCGO10000 permit.