NCC210774_NOT Signed Certification_20210910

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
532 N. Salisbury Simm, 61}1 floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: NCC210774
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Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement representation, or
certification in any application, record, report, plan, or other document filed or required lobe maintained under
this Article or a rule rrT:t71e;:;c r::iry ilrii At iie fie ... alrufl be built y cif o Clr,<s 2 rnkdt-rttt',irtt)t wi?it it ,rruy hIf i1„it' t, rwf'
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:
*LP all °n:porsib!e person: UVl LGL V fry uz"'0V,S
Title of Legally Responsible Person: �Ji? t1� motr `l
"Signature'. a () nAlt'. '11101 ZDI1
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
IMPOR7AN7 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
with Part IV, Section R, ltem (6) of the N0001(YM permit.
formation on signatory requirements, see Part IV, Section B, !tern (6) of the NC6010000 permit.