NCC190203_NOT Signed Certification_20210809

NC ®1 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: j
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Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6's Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
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DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE.FORM YOU.MAIL MUST BE COMPL TED (ITIi J.N.ORIGIN AL SIGNATURE NOT D GITAL) f4TUIR 122.221
General Permit Certificate of Coverage (COC) No.:
Name of Project: /-en4e 4,-7 —
Per NC General Statute 143-215.0(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. /r�
Legally Responsible Organizational Entity: IV6 bU.//A! Aee sakrea �e�.+�•"ts'�oh
*Legally Responsible Person: .S IC WA r`• T-rCt:lee
Title of Legally Responsible Person: s1r'*C- 0A 6^1 t09•er
*Signature: Date: 9/-R-740al
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 iV,Section B, Item (6)of the NCGO10000 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NCGO10000 permit.
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