NCC202371_NOT Signed Certification_20210716

NCG01 Notice of Termination (NOT) Certification Form
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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, 0 Floor
1612 Mail Service Center
Raleigh,NC 27699-1612
General Permit Certificate of Coverage (COC) No.:
Name of Project;
Per NC General Statute 143-215.6B(1), 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:
I, as an authorized representative, hereby request rescission of coverage underthe 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: C-
* Legally Responsible Person: 1
Title of legally Responsible Person: }
Signature: Date:
*IMPORTANT NOTE: This form must be signed by a responsible corporate officer that awns 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 NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.