NCC211985_NOT Signed Certification_20220118

NCGO1 Notice of Termination (NOT) Certification Form
Dire ions:
Print this form, complete, scan and upload to the electroniE NOT IRescissfor
Then, mail the original signed form to the NC DEMLR Stormwater Frogra
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6" Floor
1512 Mail Service Center
Raleigh, NC 27699-1612
DO N01 MAIL THIS FORM LINTILYOU R NUT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST RE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 122.221
General Permit Certificate of Coverage (COC) Na.: N ( L a. I I `
Name of Project:
Per NC General Statute 243-235.68 (i), any person who knowingly makes any false storement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained tender chic
Article or a rule implementing this Article ... shall be guilty of o Class 2 misdemeanor which may include a fine not
to rxcced ten thousand dollars ($ I0,0001.
Under penalty of law. I certify that:
I, as an, authorized representative, li-ereby request resCls,ion of coveragt= under the NFDES Stormwater Permit fur
the 5ublect taciltty i am familiar wtth the information contained in this request, and to the best of my knowledge
and belief. 5iirh information is trUC. Cornplee, and accuratc
Legally Responsible Organizational Entity: (LA•���i,�f�-
'Legally Responsible Persony u S- ",J I /�T ,�
Title of Legally Responsible Person:
*Signature:
Hate:
Print name and Title of Signed (only if authorized individuai signing differs from Legally Responsible Person):
IMPORTANT NOTE: This )oral roust be signed by o responsible corporate officer that owns or operates the
cons rrucfio►r ocrivity, such as a president, secretory, treasurer, or vice president, or a manager rho is authorized in
arcardance with Part IV, 5ecrian B, Item (6) of thr NCG010000 permit.
For more information on signatory requirements, see Part iV, Section B, Item (E) of the NC6010 ?D permit,