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Home My WebLink AboutNCC201624_NOT Signed Certification_20220211NCG01 Notice of 'Termination (NOT) Certification Form Directions: Print this form, complete, scan and upldad to the electronic NOT (Rescission) form. Then, mail the original form to the NC DEMLR Stormwater Program at: Division of Energy, Mineral & Land Resources Stormwater Program 512 N. Salisbury Street, 6th Floor 1612 Mail Service Center Raleigh, NC 27699-1612 General Permit Certificate of Coverage (COC) No.: CC 20l (p 2- Name of Project: Per NC General Statute 143-215.6B (1), any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other documentfiled 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: 0t 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: -7 k- . `-UCQ-2Sr "o * Legally Responsible Person: err r--J Title of Legally Responsible Person: l J "� t v- -- S �� Signature: Date: *IMPORTANT NOTE. 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 IV, Section B, Item (6) of the NCG010000 permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit. NCG01 Notice of Termination (NOT) Certification Form Directions: Print this form, complete, scan and up] dad to the electronic NOT (Rescission) form. Then, mail the original form to the NC DEMLR Stormwater Program at: Division of Energy, Mineral & Land Resources Stormwater Program 512 N. Salisbury Street, 6th Floor 1612 Mail Service Center Raleigh, NC 27699-1612 General Permit Certificate of Coverage (COC) No.: _�J C 0 2,o l 6 'Z Name of Project: 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 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 enalty 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: * Legally Responsible Person: ` J e r- l Title of Legally Responsible Person: Signature: CCU JLSt vI r11'1�'Sc ate: Z - (k . 2-2— * IMPORTANT NOTE: 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 IV, Section e, Item (6) of the NCGO10000 permit. For more information on signatory requirements, see Part IV, Section e, Item (6) of the NCGO10000 permit. NCG01 Notice of Termination (NOT) Certification Form Directions: Print this form, complete, scan and upldad to the electronic NOT (Rescission) form. Then, mail the original form to the NC DEMLR Stormwater Program at: Division of Energy, Mineral & Land Resources Stormwater Program 512 N. Salisbury Street, 61h Floor 1612 Mail Service Center Raleigh, NC 27699-1612 General Permit Certificate of Coverage (COC) No.: _ �-J CC, 2-6 1 U'- Name of Project: — L) " �� () U-0 Per NC General Statute 143-215.6B (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 p natty 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: * Legally Responsible Person: Title of Legally Responsible Person: rr -e s �V-VA'p e 0` Signature: �. Date: * IMPORTANT NOTE: 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 IV, Section B, Item (6) of the NCGO10000 permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit. NCG01 Notice of Termination (NOT) Certification Foram Directions: Print this form, complete, scan and upldad to the electronic NOT (Rescission) form. Then, mail the original form to the NC DEMLR Stormwater Program at: Division of Energy, Mineral & Land Resources Stormwater Program 512 N. Salisbury Street, 6th Floor 1612 Mail Service Center Raleigh, NC 27699-1612 General Permit Certificate of Coverage (COC) No.: ��C 20 l (Q 2� Name of Project: Per NC General Statute 143-215.6B (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 p alty of law, I certify that: ❑ ; 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: * Legally Responsible Person: Title of Legally Responsible Person: - X�r Q-0 s +t -OV-Vy S e r r �h -r 6- �r-1 "l,1U L S t V — P-e S Signature: Date: 2-.11.22— * IMPORTANT NOTE: 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 IV, Section B, Item (6) of the NCGO10000 permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit. NCG01 Notice of Termination (NOT) Certification Form Directions: Print this form, complete, scan and upIda d to the electronic NOT (Rescission) form. Then, mail the original form to the NC DEMLR Stormwater Program at: Division of Energy, Mineral & Land Resources Stormwater Program 512 N. Salisbury Street, 6th Floor 1612 Mail Service Center Raleigh, NC 27699-1612 General Permit Certificate of Coverage (COC) No.: J j C ri '2�61(() Zq Name of Project: ('�—)'*- 1� d «CA IA- L III Per NC General Statute 143-215.6E (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 enalty 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: 0-P * Legally Responsible Person: Title of Legally Responsible Person: Ct C2_ cti to \'J iS (. L-L— �:, L A'� Signature: Date: 2 H • z Z_ * IMPORTANT NOTE; 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 IV, Section B, Item (6) of the NCGO10000 permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.