NCC205635_NOT Signed Certification_20220201

NC 01 Noti e f Ter in Lion (No ) C rtification Form
Di
ections:
Print
this form, complete,
scar,n
u
load to the electronic
NOT (Rescission) form.
Then, mail the
origrinalsignei
f
rrn
to the NC DEM
R Sto
mwater Program at:
Division
f Energy,
Mine
I &',
and Resources
Storm
water Program
512
lis
ury Street, 61h F
oor
1
2
Ma
I Service Cente
Ra
e
gh,
NC 27699-1612
DO NO MAIL THIS FORM LINTIL YOU O REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FOR M YO i MAIL MUST BE COMPLETED Ti N ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General P rmit Certificate o C erage d ) o.: C 05 (0 35
Name of rojec : VI i U C '� t--
Per NC Gen ral St tute143-215.6Bfl),anyperso7ivh knowingly makes any false statement, representation, or
certification in any application, recorcreport, pl, in, or' they documeril filed or required to be maintained under this
Article or a i ule implementing this A 'cle ... s a e jilty of a Class misdemeanor which may include a fine not
to exceed te,7 thousand dollars ($ 0,0 0).
Under penalty of I�w, I certify th
I, as an auth rized representativE, he eby requ esd ssion of covera e unc er the NPDES Stormwater Permit for
the subject lacility I am familiarwith the infor t on contained in thi request, and to the best of my knowledge
and belief, s ch information is trL e, complete, ir d accirate.
Legally Respansible Organizational Entity: S 2,rv"C2 e 1 �- LL
*Legally Resp n 'blLible
e v e 0YY1 q S
Title of Lega I rV\a (Ae C. Y"
*Signature: Date: Z (( ' 20 2.2—
Print Name nd T� of Signed (o ly i authoriz i didual signing dif ers fr m Legally Responsible Person):
* IMPORTANT NOT This form mu t b signed by i jesponsible corpora e officer that owns or operates the
construction activity, such as a president, secret y try surer, or vice p resideit, or a manager that is authorized in
accordance ivith Part IV, Section B, Item (6) of thi ACO)10000 permit.
For more in rmat on on signatory requirements, see A7rt IV, Section 8 Item 6) of the NCGO10000 permit.
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III
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