NCC191500_NOT Signed Certification_20210902

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the vriginalsigned form to the NC DEMLR Stormwater Program at:
Division of Energy,,.Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 611 Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AN,D APPROVED.
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General Permit Certificate of Coverage (COC) No.:
Name of Project; Easton Elementary School
NCC191500
Per NC General Statute 143-215:68 (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.. shot/ 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 5tormwater 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: Winston_S
*Legally Responsible Person: Colon Moore
Title of Legally Responsible P
*Signature:
County
Construction
)]ate:
9-2-2021
Print Name and Title of Signed only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANT NOM: 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 NC6010000 permit.
For more information on signatory requirements, see Part IV, Section B, item (6) of the NCGO10000 permit.