NCC202303_NOT Signed Certification_20210729

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, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NO-i' HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST ICE COMPLETED WITHAN N Ol iG €$.+FAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: C!2 C 2 QQ3 t23
Name of Project: E
Per NC General Statute 143-215.68 (i), 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 under the 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:
*Legally Responsible Person: :-70C Sev'? v
Title of Legally Responsible Person:
*Signature-,
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* iMPORTANT 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 1V, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV,_ Section 8, Item (5) of the NCGO10000 permit.