NCC190767_NOT Signed Certification_20210809

NCG01 Notice of Termination (NOT) Certification F(
Directions:
Print this form,complete,scan and upload to the electronic NOT(Rescission)forr
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, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPF
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [
General Permit Certificate of Coverage (COC) No.: �i�L_( j C2 Gj
Name of Project: 1 LrJS I ,1 C (X„� j /UC20S
Per NC General Statute 143-215.6E(i), any person who knowingly makes any false statement, reps
certification in any application, record,report,plan, or other document filed or required to be mair
Article or a rule implementing this Article. . .shall be guilty of a Class 2 misdemeanor which may it
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 Stormv
the subject facility. I am familiar with the information contained in this request,and to the best of
and belief,such information is true,complete, and accurate.
Legally Responsible Organizational Entity: h,�t U/1 �! (' nt(AL h 0✓�
*Legally Responsible Person: uCV
L4 rI ,
Title of Legally R or�sible Pe on:
*Signature:" : Date:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsibl,
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operc
construction activity,such as a president,secretary, treasurer, or vice president, or a manager that
accordance with Part IV,Section 8, Item (6)of the NCGO10000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCGO10000