NCC202477_NOT Closeout Documents_20210811

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 signed form to the NC DEMLR 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
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
r1*1194ORM YE20 MAIL MUST BEE COMPLETED WITH AN OR11SiNAL SIGNATURE(NOT WGITAL)[40OR 121.221
General Permit Certificate of Coverage (COC) No.: JJ C—C— 2O Z Y 7 7
Name of Project: 60T 780 9 /u2L lf4Az ZkkiC.. A"o L'CC:
Per NC General Statute 143-215.6E(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 NPDE5 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: -,4 04> DA e— �/'qQp� ! 1 e,5 44 C.
*Legally Responsible Person: At ?A7 A
Title of Legally Responsible Person: C.A—
*Signature: Date:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
*IMPORTANT NOTE: This farm 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.