NCC204370_NOT Signed Certification_20220126

NCG01 Notice of Termination (NOT) Certification Farm
Directions:
Print this form, complete, scan and upload to the electronic NOT [Rescission] form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
S12 N. Salisbury Street, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAILTHIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.: _NCC204370
Name of Project: _2018 Collection System Rehabilitation Project
Per NC General Statute 143-215.5B (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 implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine
not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subject 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 Organizational Entity: Town of Troutman
*Legaiiy Responsible Person: Ronald
Title of Legally Responsible Person: _Town Ma
*Signature:
Date: V--/a-- (
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANTNOTE: 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 1V, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 6, Item (6) of the NCGO10000 permit.