NCC205406_NOT Signed Certification_20211110

NCG41 Notice of Termination (NOT) Certification Form
Directions;
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original form to the NC DEMLR 5tormwater Program at:
Division of Energy, Mineral & Land Resources 5tormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Genera[ Permit Certificate of Coverage (COC) No.: vuTV`i✓
Name of Project:
A
Per NC General Statute 143-215.6B (1), any person who knowingly makes any false statement, representation,
or certification in any application, record, report, plan, or other document 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).
Uq4er penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES
Siormwater 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: ,H:� 1W� 'r`► i S
* Legally Responsible Person:
Title of Legally Responsible Person:
Signature:
Date:
* IMPORTANT NOTE: This form 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 a manager that is
authorized in accordance with Part IV, Section B, item (6) of the NC6010000 permit.
For more information on signatory requirements, see Para' IV, Section 8, item (6) of the NCGO10000 permit.