NCC202524_NOT Signed Certification_20210723

NCG01 Notice of Termination (NOT)
Directions:
Print this form, complete, scan and upload to the electronic
Then, mail the original signed form to the NC DEMLR Sto
Division of Energy, Mineral & Land Resources Stor
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN RE
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATU
General Permit Certificate of Coverage (COC) No.:
Name of Project: / - IQ-
-a
Per NC General Statute 143-215.6B (i), any person who knowingly makes any fi
certification in any application, record, report, plan, or other document filed or
Article or a rule implementing this Article ... shall be guilty of a Class 2 misden
to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage un
the subject facility. I am familiar with the information contained in this regt
and belief, such information is true, complete, and accurate.
g Y p g y C.�
Legally Responsible Organizational Entity: Cori n
*Legally Responsible Person:
Title of Legally Risible Person:
*Signatu
Print Name and Title of Signed (only if authorized individual signing differs from
fication Form
(Rescission) form.
ter Program at:
Program
EWED AND APPROVED.
(NOT DIGITAL) [40 CFR 122.221
statement, representation, or
aired to be maintained under this
or which may include a fine not
e NPDES Stormwater Permit for
nd to the best of my knowledge
Date: ;
Responsible Person):
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer at owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, ir 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) f the NCG010000 permit.