NCC206011_NOT Signed Certification_20211014

NCGO1 Notice of Termination (NOT) Certification Form
Directions10
.
Prink this farm, 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 &hand Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 fail Service center
Raleigh, NC 27699-1612
DO, NET Vitt L THIS FORM UNTlL YOU NOT REQUEST HAS BEEN RE11lElIVEp AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE SNOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.:
Name of Project: \-Ji✓�/�l-%r1 L__CT (-Ij-q
Per NC General Statute 143-215.6B (i)., any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article or ❑ rule implementing this Article ... shcrlJ be guilty of a Class z misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000).,
Under penalty of law, i certify that:
1, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subiect fad litI a m fora 11 is r with the 1 nfo rmatio n co nta i ned in this req uest, and to the best of my k n owledge
and belief, such information is true, complete, and accurate.
Legally ReS onsihle Organizational Entity: � � '�`� ��'� -•-�- ��
*legally Responsible Person: �f �iM+ ,�V��
Title of legally Res
*Signature:
i
r o 7 F +
Date: � � � `ldF
2J
Print Name and Tit fe of Signed (only if authorized in di signing 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 a president, secretary, treasurer, or vice president, or d manager that is authorized in
accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information an signatory requirements, see Part IV
,, Section B, Item (6) of the fVCGn10000 permit.
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