NCC213474_NOT Signed Certification_20220613

CG03- Notice of Termina-tion (NOT) Certi icafaon r orrn
Directions:
Print this form, cornpleie, scan and upload to the electronic NOT (Rescission) form,
Then, mail the oricirio-isiaried form to the NC DEMLR Stormvdater Program ai:
Division of Energy, MiInel-al �i�. Land heSOUi`Ce5 Si01`lii'JJatel" rOgl-aiii
512 N. Salisbury Street, 6t1i Floor
1612 Mai! Service Center
Raleigh, I`C 2/699-1612
DO NOT MAIL THIS FORM € NTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORFA YOU MAIL MUST BE COMPLETED FAJITH AN ORIGIMALL SIGNATURE (NOT DIGITAL) [40 CFR 12212]
F _ ( ! �4 (.LL
General Pcrrrit �,e!�'�ii�cate oi� Coverage (HOC) fro.. ,Iv L��ud__
Name of Project: C 'U,
Per NC General Statute 143-215,6B (i), ony person who knowingly makes o.ny false statement, representation, or
certifcation in any application, record, report, plan, or other document filed or requij . to be maintained under this
Article or a rule implementing this Article ... shall be guilty of o Class 2 misdemeanor v✓h,ich may include o fine not
to exceed ten thousand dollars ($10,000).
,
Under p2 naiiy or! !avJ, I C2rLily that;
aS an authorized repcSefalJe; nC"eb;IeuUeSL reSCiSSIOn of Cove —rage Lit der e NP)H . Storn vJat r Permit fort
_
the SUiJ;eCC TaC!Iii`II. I ar i fai?!Iklar ;i%iii, tl e li iC ilic_ir:1 GCnt_J!I Ci !!l :I"!IS c j! eSt, c;n C.
``r cSt Jf i`":';!
and belief, such inforrnaTlon Is true, complete, and aC(-ura'"e. -
Legally Responsible Organizational Entity:
'Legally Responsible Person:'[
Title of
�'�Signatu
possible Person:
A
Date: V�f ZL
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, treasurer, or vice president, or a monoger that is authorized in
accordance with Part1V) Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.
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