NCC203621_NOT Signed Certification_20211005

NCGOI Notice ®f Term Inati_i-! %�'��'�'`
Direction
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
512 N. Salisbury Street, 6''' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
'!C In "" E�E:"a REVIEWED AND APPROVED.
-Va a;; .�av %Wvu%JaiWAL S;GNATLIRE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.: N �-CJ03
Name of Project: S I let' C&L, eel
Per NC GeneralStatute 143-215.68 (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other docum nt filed 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, 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: 14 blbb5 Rct vYA , I -L to J e xi eI��S
*Legally Responsible Person:
Title of Legally Responsible Person:
*Signature:
Print Name and Title of Signed (only if
* IMPORTANT NOTE: This form must be signed b a
construction activity, such as a president, secre arl
accordance with Part IV, Section 8, Item (6) oft e
5
Date: /0 _ 5--C7�
signing differs from Legally Responsible Person):
nsible corporate officer that owns or operates the
surer, or vi ie president, or a manager that is authorized in
10000 permit.
For more information on signatory requirement, seo Part IV, Section 8, Item (6) of the NCGO10000 permit.