NCC214172_NOT Signed Certification_20220622

N(G01 Notice of Termination (NOT) Certification Form
Directions:
rint 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 Mail Service Center
Raleigh, NC 27699-1612
DON T MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM Y U MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
,r' ! /
General Per t Certificate of Coverage (COC) No.:
Name of Proj' ct: C f
Per NC General Statute 143-215.6E (i), any person who knowingly makes any false statement, representation, or
certification in y 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 t usand dollars ($10,000).
Under penalty # law, I certify that:
I, as an authori2; d representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subject facij'j ty. I am familiar with the information contained in this request, and to the best of my knowledge
and belief, suc '',information is true, complete, and accurate.
Legally Responsble Organizational Entity: -'��Crr''Fi
*Legally Respon�lble Person: a`'%L'9 � 201-e�
Title of Legally esponsible Person: Apr, ;i'm i
*Signature: C ✓�" I Date: 6, Z
Print Name an .Title of Signe .(only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANT N TE: This form must be signed by a responsible corporate officer that owns or operates the
construction ac ivity, 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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.