NCC191441_NOT Signed Certification_20210806

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 form to the NC DEMLR 5tormwater Program at:
Division of Energy, Mineral&Land Resources Stormwater Program
512 N.Salisbury Street, 6ch Floor
1612 Mall Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.:
Name of Project: GJC' �
Per NC General Statute 143-215.6E(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 . . .sha11 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: y�
Title of Legally Responsible Person: nT —
Signature: Date' (i
*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 B, item (6)of the NCG010000 permit.
For more Information on signatory requirements,see Part IV,Section B, Item (6)of the NCG010000 permit.