NCC210708_NOT Closeout Documents (2)_20220303

NCG01 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 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.: gC-(- a i O -7 O 9)
Name of Project
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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 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:
1, 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. II ,,
Legally Responsible Organizational Entity: A4 S ° �- Lo-1-4
*Legally Responsible Person: Al-�"
Title of Legally Responsible Person:
*Signature:
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ate:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary,
ovicepresident, or a manager that is authorized in
the NCGOIOOOO
accordance with Part 1V, Section B, item (6) f permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
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