NCC203912_NOT Signed Certification_20210913

NCGO1 Notice of Termination (NOT) Certification Form
Directions.
Print this form, complete, scan and upload to the electronic NOT (Rescission) dorm.
Then, mail the orrginalsigned firm to the NC DEMLR Stormwater Program at:
Division of energy, Mineral & hand Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Flail Service Center
Raleigh, NC 27699-1612
DO
NOT
MAIL
THIS FARM UNTIL YOUR NET REQUEST HAS BEEN REVIEWED
AND APPROVED,.
THE FORM
YOU
MAIL
..............
MUST BE COMPLETED WITH' AN t)RIGlNAL SIGNATURE (NOT
DIGITAL) [40 CR 3.22,22]
General Permit Certificate of Coverage (COC) No.:
Name of Project:
ME
,0 4-L., 7,5::)
91Z
Per NC Genera! Statute 143-215.58 (i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, or other documentfiled 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, f certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPpES 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: �1� �t� 5e
*Legally Responsibly Person:
Title of Legally Resp
*Signature:
(F, I (...
Date
�/ I S17. f
Print Name and Title of Signed (on ly ►#authorised indlvrdua! signing differs from Legally Responsible Person):
* IMPORTi411lTIVaTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as ❑president, secretary, treasurer, or vice president, or a manager that is authorized in
accordance with Part !V, Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV Section B, Item the NCG010000 permit,