NCC204781_NOT Signed Certification_20211013

NCGO1 Notice of Termination (NOT) Certification Form
Directionso,
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the orlginalsigned form to the NC DEMLR Stormwater Program at:
Division of energy, Mineral & Land Resources Stormwater grogram
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
al i h{ NC 27699-1612
DO NOT MAIL THIS Fi7RIVl UNTIL YOUR NET REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN Q�IGIN�L SIGNATURE (NOT DIGITAL) [40 CR 3.22.Z2]
General Permit Certificate of Coverage (COC) No.: � 6--e L- '2W-0J4 r-74�?
Name of Project:
Per NC General5iatuie 343-235.5B (i), any person who knowingly makes any false statement, representation, or
certrficatiorr in any application, record, report, plan, or other documentfiJed or required to be maintained under this
Article or cr rule implementing this Article ...shall be guilty of a Class 2 misdemeanor which may include ❑ dine not
to exceed ten thousand dollars ($10,000).
Under penalty of law, i certify that:
I, as an authorized representative, hereby request rescission of cove rage under the NPDES Sto rmwate r 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 tree, complete, and accurate.
Legally Responsible organizational Entity: �� �� �L` � � ��� f � Col
*Legally Responsible Person. �� — �
Title of Legally s si erson:
*Signature: Date: � � � � Z
%
Print Name and Title of Signed Manly if authorized indrviducr! signing differsfrom Legally Responsible Person}:
* IMPORTANT NOTP Thisform must be signed by a responsibie corporate officer that owns or operotes the
construction activity, such cis a president, secretary, treasurer, or vice president, or a manager that is outhorized in
accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more Information on srgnafory requirements, see Part IV,, Section 8, Item (6) of the NCGD10000 permit.