NCC203414_NOT Signed Certification_20210805

NCGO1 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 OEMLR 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
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General Permit Certificate of Coverage (COC) No.: NCC203414
Name of Project: Sassadxa Swamp Mitigation Site
Per NCGeneral Statute 143-215.6B(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 o fine not
to exceed ten thousand dollars($10,000).
Under penalty of law,I certify that:
1,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: Wildlands Engineering, Inc
*Legally Responsible P rs John Hutton
Title of Legally Res ns le Per n: Vice President q
*Signature: Date:
Print Name and T e of Signe (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 IV,Section 0,Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.