NCC203162_NOT Signed Certification_20220717

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
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, 611 Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
❑O 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) [40 CFR 122.221
General Permit Certificate of Coverage (CDC) No.: Nice Z03 (rya
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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:
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 knowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity:
*Legally Responsible Person:
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Title of Legally Responsible Person: _ LOmr- oWf'K
*Signature:
Date: 2.Z.
Print Name and Title of Signed (only if authorized indfvidual signing differs from Legally Responsible Person):
* IMPORTANTNOTE. 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 NCG010000permit,
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