NCC204277_NOT Signed Certification_20211031

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form,
Then, mail the original signed form to the NC DEMLR Storm water Program at:
Division of Energy, Mineral & land Resources 5tormwater Program
512 N. Salisbury Street, a Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
D❑ NOT MAIL THIS FORM UNTiL YOUR NOT REQUEST HAS BFIFN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR LU-22)
General Permit Certificate of Coverage (COQ No.,
Name of Project: v- -7Z
Per NC General Statute 143-215.68 (i), any person: who knowingly makes any false statement, representation:, or
cernf cation in any application, record, report, plan, or other document fled or required to be maintained under this
Article or a rule implementing this Article ... shall be guilty of a Cuss 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 Stonmwater Permit for
the sub*a 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: is
'Legally Responsible Person: TOM aur�rn �5L•
T-rtle of Legally Responsible Person. NAG 64r—
"Signature:IA�--
Date: 10 7— 2
Print Name and Title of Signed {only if authorized indivldualsigning differs from Legally Responsible Person):
IMPORTANTNOTE. This form must be signed by o responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is authorized in
accordance with Part iV, .Section 6, Item 16) of the NCGO10000 permit.
For more information on signatory requirements, see Part iV, Section 8, item (6) of the ►VCG010000 permit.