NCC200248_NOT Signed Certification_20220209

NCGO1 Notice of Termination -(NOT) Certification Former
Directions:
Print this form, complete, scan and u pIoad to the electronic NOT {Rescission} form.
Then, rnall the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Larrd Resources. Stormwater Pro grarn
512 N. Salisbury Street, 6' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL TH IS FOFt M UNTIL YOUR NiDT REQUEST HAS BEEN REVi EWER AND APPROVED.
THE FOW YOU MA 1. L MUSE BE COMPLETED wTrM AN ORIGINAL SIGNATURE (NOT DIGITAL) [e40 CFR 122,721
General Permit Certificate of Coverage (COC) Na.: [--I C- 0u Z 4
Name of Project, 5 cr_5a-� '1 i
Per NC General .Statute 143-2 15.6B (i), any person wh(a knowingly makes troy foIse sto�ement, representotior+, or
cerriffcotiorr in ony oppfication, record, report, plan, or other document fifed or required to be main torned under this
Artide or a rule implementing this Articie ... shOf be guihy of a Class 2 mh0erneanor which rrray include a fine not
to exceed tern thousand doflars ($10, 0).
Under penalty of law, I certify that=
f, as an authorized representative, hereby request re5Cission of coverage under the NPDES Stormwater Permit for
the subject facility. I am famiiia r with the information contained in this request, and to the best of my kriu ledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity: T9-7- PL _S
*Legally Responsible Person: t lD
Title of Legally Ruspdn5ible Person:
"Signature:
Date: A { 2�0L'-
Print Name and Title of Signed (only if authorized indMduat signing differs from Legaify Responsible Person):
* IMPORTANT NOTE: This form must be signed by o responsVe corporate officer that owns or opera res the
construction activity, s+ich os a aresidernt, secretary, treasurer, or vice president, or a manager that is authorized In
accordance with Part IV, Section S, item (bj of tine NCC01C000 permir-
For more information an signatory requireme nts, see Part IV, Section 8, Item (6) of the NCG0I0000 permit.