NCC203844_NOT Signed Certification_20210927

NCGO1 Notice of Termination (NOT) Certification Form
irections,
Print this form, complete, scan and upload to the electronic NOT (Rescission) farm.
Then, mat {the vriginal signed form to the NC ❑ MLR Starmwater Program at:
Division of Energy, Mineral &Land Resources Starmwater Program
512 N. Salisbury Street, 6`'' Floor
1612 ail Service Center
Raleigh., NC 27699-1612
DO NOT MAIL THIS FaRiUl UNTIE YOU R N OT REQLiEST HAS BEAN REVIEWED AIVD APPRQIIED.
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^ FORM_YDU.�1iiA[. MUST BE COMPLETED 1�11[iH AN ORIGINAL SIGNATUR-E (NOT DIG-ITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) Na.:
Name of Project:
ew �w i i:1 2A"e- - - - 0 alt; 2 U
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C'3e,
1 leE�`1�L,
Per NC General Statute 143-235.68 (i), any person who knowl"ngly makes any false statement, representation, or
certification in ony application, record, report, plan, or other document fried or required to b e mainfained under this
Article or o rule implementing this Article .. , shalt be guilty alp Class 2 misdemeanor which may include afin e 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 hest of my knowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity:
*Legally Responsible Person:
Title of Legally Resp SUAa►Person:
`Signature:
!$01 P
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o& AIJ
Date: B/L7/ Z
Print N a m e an d Tit Ie of S i g n e d (only if auth ortzedin dividuall`ire g differs from Legally Responsible Person)
* IMPORTANT NOTE: Thisform must be signed by a responsible corporate officer that owns or operates the
construction activity, such as o president, secretary, treasurer, or vice president, or a manager that is authorized in
accordance with Part IV, Section B, item (6) of the IVCGQ10000 permi'i.
For m ore inform ation o n Signatory requiremen ts, .see Part I V, Section B, Item of th e NCG01 0000 perm r` .
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