NCC203931_NOT Signed Certification_20210917

NCGO1 Notice of Termination (NOT) Certification Form
D i rectkm:
Print this form, comoie-- _- a-d uoioaad to the eiectrc- _ - ?esi-—
Then, mail the ariglnci signet' `orm to ti-e NC_-
DMsion of Energy, Miners 1. Land Resources Ste �- N = =- -
512 N. Saiisbtry Street. 6 b FZov,
1612 Mail Service Center
Rale+gh, NC 27649-1612
DO NOT MAIL THIS FORK! UNTIL YOUR NOT REQUEST = : _ .' ZTHE FORM YOU MAIL WST BE COMPLETED WTT H AN OftakAL SbG
General Permit Certificate of Coverage (COCI No.: NCC2039-"'
°Jame of Project: Kudrow Lane Culvert RepkKxxTwd
Per NC General Statute 143-215.6B (i), any person who knowingly max=
certification in any application, record, report plan, or other docur^ = - _ .
Article or a rule implementing this Article ... shall be gL*y of a CCSZ
to exceed ten thousand dollars ($10,000)-
Under penalty of law, I certify that
I, as an authorized representative, hereby request res6ssicr c- ZZ .
the subject facility. I am familiar with the information con a ^er
and belief, such information is true, complete, area acc ra-e_
L egally Responsible Organizational Entity: Duke Enemy PTNTess- LLC
"Legally Responsible Person: Rarely Veitri
Title of Legally Responsible Person: DkiectoroffrartsrnisiortPerrtvlbrV
h
'Siena t Lt + 0am �--
Print Name and Title of Signed [only if authorized indAeOutd signing dtffers from [ega iy . c• j, :
IMPORTANT NO TE: This form must be signed by a responsi mTorotee of ker that awr=s .x oaer=-ate -•e
construction activity, such as a president, secretary, truer, ar NiW presiders or c marccer
accordance with Part IV, Section B, item (6) of the NCGO10000 perm -
For more information on signatory requirements, see Part IV, Section k Rem (6) of tip ftC_"L: - =(zr_ _e