NCC210524_NOT Signed Certification_20211129

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
pis form, eomoete, son and upload to the electronic NO (Rescrssaori) form
, mail the original signed form to the NC DEMLR Stofmvrater Program at.
Division of E nergy, Mineral & Land Resources Stormwa ter Program
S12 N. Salisbury Street, 6"i Floor
1612 Mail Service Center
Raleigh, NC 27699 1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 C F R 122.221
General Permit Certificate of Coverage (COC) No.
Name of Project: x?913 96-&iati 4*"fy ,eA
/WC ZIo s-a y
Per NC General Statute 143-215.68 N any person who knawingly makes any fats- stoletrient, representation, or
certi fx atton rn any oppli[oiion, record report, plan, or other locum-nt f ik-d or r-quire-d to be mornt uyned under On
AnxJe or a rule ►mPJen;en[my this Article. , shall by gwfty ni a CkLu 1 mistk-mennor which may in-clude o fine not
to exceed ten thousand doSars ($f0,0M).
Under penatty of law, I ri-rtify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the sub#ect 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 Organi7ational Entity -
'Legally Responsible Person: bAA11,61 14447'!^f-�
Title of Legally Responsible Person:
•Signatwe: _ _
-
- Date:
Print Name and Trtle of signed (only if authorized individual Signing differs from Legally Responsible Person):
' MMPCWTAMT PK"E Tries form must be shyned by a r sponublr aorporatr dfkzy that owns or operates Ow
construction actmity, such as a president, secretary, treasurer, or mice president, or a manager that is outhmzed in
accordance with Part IV, Section B. Item (6) of the NCG01 0000 permit -
For more ir►jnrmabon on signatory requirements, see Port 1V, Section R, trem (6) of the NCG01WW permit_