NCC213054_NOT Signed Certification_20220706

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the elletronic NOT (Rescission) form.
then, mail the original signed Corm to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) 14+0 CFR I2.Z.221
General Permit Certificate of Coverage (COC) No.: 1 ��
Name of Project: S! 11DfUC � a 4l 2-2-
Per NCGeneral Statute 143-215-68 (i), any person who knowingly makes any false statement, reWese>nration, or
certification in any application, record, report, plan, or other dexument filed or regurred to be maintained under this
Article or a rule implementing this Article. shall trw guilty of a Class 2 misdemeonor 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, lam familiar with the information contained in this request, and to the best of my knowledge
and b-4ief, such information is true, complete, arrd accurate.
Legally Respomible Organbational Entity: 6iVL ryC ej
'Legally Responsible Pertinn. 1.0 it n Y�l _
syvo-T
Title of Legally Res IF on:
Signature: '°' C"' Date: ,-111gl Z
Print Name and Title of Signed { Jjlqurhorized individual signing djffers from Legally Responsible Person):
• IMPORTANT NOTE: This form must he s+goed by a responsiirle corporate officer that owns or operates the
construction activity, such as a presidenr, secretary, treasurer, or vice president, or a manager that is authorized in
accordance wrth Part 1V, Section 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part W, Sect►0n 8, Item (6) of the NCG010000 permit.
]rye
►t l