NCC202596_NOT Signed Certification_20220617

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the eIectronic 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, 6`h Floor
1612 Mail Service Center
Raleigh,, NC 276994612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLEMD WITH AN ORIGINAL SIGNATURE (NOT DIG17AQ [40 CFR 221
General Permit Certificate of Coverage (COC) No.: NIL bvQ C-l"scc �� ��#) I---tL C L4 k8 G 2o�e ��67q�
Name of Project:
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Per NC General Statute 143-215.6B (i), any person who knowingly makes an alse statement, representation
certification in any application, record, report, plan, or other document fled or0
, or
Article or o rule implementing this Article ...shall be guilt of a Class 2 misdemeanor egwred to be maintained under this
Y sdemeonor which may include o 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 knowled e
and belief, such information is true, complete, and accurate. g
Legally Responsible Organizational Entity: �, (A)Q,50 -� �'Y1
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*Legally Responsible Person: �I �C� 1)dV)r1 t!n 1n � I i lnri
Title of Legally "iblerers n C,Q—Qgj}JvA10'
*Signature:
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date:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANT NOTE.-, Thisform must be signed by a responsible corporate officer that owns or operates the
mwn�
construction activity, such as a president, secretary, treasurer, or vice president, or o 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, Section B,, Item (6) of the NCG010000 permit.