NCC201810_NOT Signed Certification_20210723

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan 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, 6`h 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 BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (CDC) No.. --
Name of Project:
Per NC General Statute 143-215.66 (i), ony person who knowingly makes any false statement, representation, or
certij"ication in any application, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article ... shah be guilty of a Class 2 misdemeanor which may include a fine not
I exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that'
I, as an authorized representative, hereby request rescission of coverage under the NP0E5 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
*Legally Responsible Pei son: —_—...-
Title of Legally Responsibie Person
*Signature:
Print. Name and Titie of Signed (only if authorized individual signing differs from legally Responsible Person):
* IMPORTANTNOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, r,r vice president, or u manager that is authorized in
accordance with Part IV, Section 8, Item (6) of the NC0010000 permit.
f'or more information on signatory requirements, see f Grt IV, Sectror. B, Item (6) of the NCG010000permit.