NCC203631_NOT Signed Certification_20210806

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 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
General Permit Certificate of Coverage (COC) No.: � J
Name of Project: kQ�ba��
Per NC General Statute 143-215.6E (1), any person who knowingly makes any false statement, representation,
or certification in any application, record, report,pion, 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:
title of Legally Responsible Person:
Signature:
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.