NCC203201_NOT Signed Certification_20211115

NCG01 Notice of Termination (NOT) Cert;ffification Form
Directions:
Print this form, complete, scan and upload to thp elertronie NOT IResi-issian� fo----
Then, mail the original signed farm to the NC DEMLR Sfiormwater Program a1
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, nth koor
� 1612 Mail Service Center
Raleigh, NC 27599-1612
DA IV�3T NE���. THIS FORM UNTIL YOUR NET REQUEST HA5 BEEN REVIEiNEI) AND J4PPROVEiQ,
THE FORM Y0U MAIL MUST $E-COPLE7ED WITH AN _0RJ
$[G NATU R-E (NflT DIGITAL) [40 CFR 122'221
General Permit Certificate of coverage (CDC) Na.:
Name of Project: ��� � � ���,�� X)ji V /"t
Per NC Genera! Statute 14.3-215.68 (i),, any person who knowingly makes one false sfatement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article or cr rule implementin g this Ar-ticle ...shall be guilty of a Class 2 misdemeanor which may include Q fine got
to exceed ten thousand dolfars ($10,0oo).
Under penally of law', I certify that:
I, as an authorized representative, hereby request rescission of coverage under the N-PIDE ormwater Permit for
the subject facility. [ am familiar with the information contained in this request, and to the best of my knowledge
and belief, such information is tare, complete, and accurate.
Legally Responsible Organizational Entity:
i
*Legally
Responsible Person. C-,
Title of Legg d f Res po n i b e Person: -
M
'� i r� f u r: r :�d
Date.
Print Name and Title of Signed (only if authorised individual signing differs#rom Legpcmsib, person}:
IMPORTAIVT NOTEI Thisform must be signed by a responsible corporate officer t o t owns or oera tee
he
rly� rr activity..
�j�y�7� rryf}� ray! y.� � �
construction ctJ Y� c i it } -such 7� Yt president, ecrY tar treasureraccordance W1 • • in
fr� vice president. r a manager that i, authorized
t igrt I� e ct o Items o th e NCGO1 0000 permit.
For more information on 5 utor r� it m t� e Part I(6)•
ctro # Item o the eri�