NCC201956_NOT Signed Certification_20220222

NCG41 !Notice of Termination (NOT) Certification Form
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
512 N. Salisbury Street, 6`h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVVD
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 140 CFR 122.221
General Permit Certificate of Coverage (COC) No.:. 9C&201 q5- Co
Name of Project: sl Lc Ave oodt - C4oveyG
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 rhis
Article or a rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may incluae o f ino no,
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 Stormwatr • 'c r
the subject facility. I am familiar with the information contained in this request, and to the best of my f rr
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity:
*Legally Re
Title of Le,
*Signature
Print Nam
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CSn;1
* IMPORTANT NOTE. This farm 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 authorizers' in
accordance with Part IV, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.