NCC211025_NOT Signed Certification_20211015

NCGQ1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, ron%pt4e, scan and ugbad to th&eWtrpnk. NOT (AeScission) form.
Then, rriaii the arFglnal sfgned fo m to the NC 6i`101-11stormwater. P"raru -at:
uii 6i6n of Enerr, Mineral & Urrd Resuurtms Sturm w;Aer Pftram
sit N. Salisbury Street, FIQQ'r
16U Mall Sar<rice Center
Raleigh, NC 27699-1&12
Dd Nam{ MJAILTH3 r-01111A UNTIL YOUR NOT REQUEST HAS M N REVIEWED AND APPftOVECE.
THV FORM VOID MAIL MUST BE COMPtETEp Vr1" AN CIRIGtNAL SM110URE,414M PWITAW 140 CFR M221
General Permit Certificate of.Cuverage ICOC) No.: � +
NarMe of Protect:,
Per NC Grneral Statute-143-215.651)), any pers<ra who k aowingly ranker atty false statumen regresentoWn, or
0ertrilcatioli in any appfkation, rkord rrepol t, Tarr, Brother daturrwat' lied or required to be Awot3altv.d under this
Arf4* or a rota ImpI nerFfiog this Attic* - - - shall hfe guilty of q Cross 2. misder maar which may fiTeJude a firm haf
for exceed fern Oousarrd dollars 1$I0, ),
L fides' penalty of Iaw, 1 WIIfy ItTal!
I, a� an authonzed reprrrsentMive, hereby request rescission of ouverage-under the Permit for
the subject facillty• i-arn fosmllw with the inf mnTa6an corTtained In this request; artd to the best of my knowledge
od belief, sv0 intormatIdn is true, ;gmpiete, and ac-rurat5-
Lce al IVHeWnsibte.arganiiational Entity_ 174'0 Ls wc- +►- ❑ LLC--
'LggoAy Respons1t71e Persber
Tide o'f Legally ReSpnrisre Irerort;
x5gnaturw.
Print Narro acid Title of 5igiied Canty ►f �udan�ized
doers from tegolly Responsiate Aerwnk:
' IMPORTANT MOTE. T&s' fgr•ra must be signed by a resporFs*e corporate officer that -owns v'r oper+jtes tht,
constrwc-tion WwrtV, such ors a psWnf, SeCWary, rreosurer, 4r vita president, ar Q rriunaper f IrptJs authQrrredlrr
accordance with Part J V, sertlan 8, item (6) of Me I GUlbow permit,
For more inf9nnatlon an s grmtorp requiremenM see Port IV.-Wtion 9, item (6) of the ivc& 10t 10 permit