NCC203346_NOT Signed Certification_20211222

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronicv u i {Rescission) form.
Then, mail the original signed form to the NC E EMLR Stormwater Program at:
Division of
Energy,,
Mineral & Land Resources Stormwate
L2 N. Sali
sbury Street, 61'' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
r Program
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED
THE FORM Yt3U MAtt lV1U rT BE COMPLETEQ WITH ANQRiGINAL SIGNATUR-E (NOT DIGITAI) [40 CFR 122u22..
General Permit Certificate of Coverage (COC) No.: �'4 �('
Name of Project:snuff" W&Emw&
Per NC General Statute 143-215.6B
certification in any application,
a
(i), any person who knowingly makes anyja-/se statement, representation, o r
record, rejreport,Tlan, or other document filed or required to be maintained under this
Article or a ruse implementing this Article ...shall be yu
to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
I., as an authorized representative, hereby request r
the subject facility. I am familiar with the informati
and belief, such information is true, complete,,
Legally Responsible Organizations
*Legally Responsible Person:
I Entity:
Title of Legally Respqpsible Person:
*Signature:
Ld
i/ty of a Class 2 misdemeanor which may include a fine not
escission of coverage under the NPDES Stormwater Permit for
on contained in this request., and to the best of my knowledge
and accurate.
Date:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* 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 8, Item (6) of the NCGO10000 permit..
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.
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