NCC211506_NOT Signed Certification_20220114

NCG01 Notice o i erm0f'Iettkmi (NOT)
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail tho original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Storrnwater Program
512 N. Salisbury Street, 6"' Floor
1612 Mail Service (:enter
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: ZZO<�a 14 0
Name of Project:
Y-t'-
Per NC General Statute 143-215.68 (i), 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 imp"crnenling this Article ... shall be guilty of a Class 2 misdemeanor �u.1h,ch n uY :r,C"L. d, a fine not
to exceed ten thousand dollars ($10,000).
Under penalty of 13w, I certify that;
f, as an authorized representative, hereby request rescission of coverage under the NPDES 5tormwater Permit for
the subject facility. i am familiar with the information container in this request, and to the b.a of '
and beiief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity:
*Legally Responsible Person: /�q / tlr'1�w'
i itle of Legally Responsible Person, V 1 ee- fp's : den. f
`Signature: Date:
Print (dame and Title of Signed (only if autlrurixed individual siyrriny differs rani L yuily Responsible rzrsar;j:
' iMPORTANT NOTE: Mrs foie: must be signed by a responsible curpcxate of)icer 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 0, item (6) of the NCG010000 pernut.
For more information on signatory require-ntents, see Part IV, Section B, Item (t) of the N G010000 permit,