NCC205563_NOT Signed Certification_20220616

NCG01 Notice of Termina ion (NOT) Certification Form
Din ctions:
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, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-161.2
00 NOT MAIL THIS FORM UNTIL YOUR NOT F EQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH A ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate Of Coverage (COC) No.:
Name of Project:
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, 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 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 rescis:
the subject facility. I am familiar with the information co
and belief, such information is true, complete, and accur�
Legally Responsible Organizational Entity:
*Legally Responsible Person: ilyki S
Title of Legally Responsible Person:
*Signature:
on of coverage under the NPDES Stormwater Permit for
stained in this request, and to the best of my knowledge
004'g:-�-S
Print Name and Title Of-&igrre5cl (only if authorized individ+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 manager that is authorized in
accordance with Part IV, 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.