NCC201880_NOT Signed Certification_20220606

NC
G01 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, 6th Floor
1612 Magi Service Center
Raleigh, NC 27699-1612
DO NQT MAIL THIS CORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED,
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122221
i
general PerM
`�t Certificate of Coverage (COC) No.: ti cc�� 1 a$D
Marne of Proje-ct:.&o61 3S61Brood
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 implemen ting this A rticle ... shall he guilty of a Cass 2 misdemeanor which may include a fine not
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 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:
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*legally Responsible Person: _ Cki s4op hide Lial'(,
Title of Legally Re
*Signature;
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Pers9p:
Date: G/no/J647,
Print Marne and Title of Signed (only if authorized individual signing differsfrom Legally Responsible Person):
* IMPORTANT NOTE: Thisform must be signed by a responsible corporate officer that awns or operates the
construction activity, such as a president, secretary, treasurer, or nice president, or cr 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. Se rtinn B, ifem 16) of the 1l1CG010Q0f) permit.
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