NCC202233_NOT Signed Certification_20220605

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this Form, complete, scan and upload to the electronic No (Rest ssion) form.
Then, mail the ordinal doted form to the NC DEMLR 5tormwater Program at:
❑lvlslon of Energy, Mineral & Land Resources Stormwater Program
517 N. Salisbury Street, 61" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM i1NTIlL YOUR NOT REQUEST HAS SEEM REVIEWED AND APPROVER,
THE FORM You MAIL MUST BE COMPLET D WrM AN ORIGUY LL SIGNATURE (NOT DIGTTAL)140 CFR 122 U I
General Permit Certificate of Coverage (COC) Neo.: ACc �x) o)
Name of Project: : �-
Per NC General Statute 143-215.68 (i), any person who knowirngty makes any false storementC 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 Articte .. shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed tern thousand dollars ($10,OW).
Linder penalty of law, I certify that.
as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Petirmlt for
the subject facility I arcs familiar with the information contained in this request, and to the best of my knowledge
and belief, such information is true, complete, and accurate.
I esally Responslble Organizational Ent lty_-
*Legally Responsible Person:
Title of Legally Responsi -Pe n: _
'Signature: A—' T
k0�-9
Date:
Print Name and Title of Signed Jonfy rf authorized individual signing differs from Legally Responsible Person)'
144PORTANTAlOTE. This form must be signed by a resparuible Corporate officer that awns air operates the
construction activity, such as o President, secretary, treasurer, nr We OreSidenf, or a manager that Is authorized in
accordance with Part IV, Section B, Item (6) of the NCG010000Permit_
For more information on signatory require mwnts. See Part IV, Section 8, item (6) of the NC6010" Perm.I