NCC202298_NOT Signed Certification_20220308

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this farm, complete, scan and upload to the electronic NOT (Rescission) farm,
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
00 NOT MAIL T415 FORPA UNTIL YOUR NOT RC.QUE5T HAS HEEN RLVI£WED AND APPROVED,
THE FOWA VOU WA ARM K CID&WU TED W"N AN OiRfWM SIGNATURE (RIOT DforrAL) 140 CFR 122.221
General Permit Certificate of Coverage (COC) No,- NCC ZO,ZZ` Z
Name of Project, PC L-0 00(0
Per NC General Statute 143-215.60 (i), any person who knowingly makes any false statement, representation, or
certificatran 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 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.
Legally Responsible Organizational Entity:
'Legally Responsible Person- KP 1 � Gou
Title of Legally Responsible Person- Prope r f g Owner „
;Signature-
3-1-7.
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 operarts the
construction activity, such as a president, secretary, treasurer, or vice president, or a manoW thins at, Fhori ed 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 NCGR1100W permit.