NCC213916_NOT Signed Certification_20220718

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, snail the orighlod signed form to the NC DEMLR Stormv%rater Program at:
Division of Energy, Mineral 8! Land Resources Storni'Water Prograrn
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 DUST BE COMPLETED EVITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 17-2.22]
General Permit Certificate of Coverage (COC) No.: Wf�,�Mqtb
Name of Project:7�l
Per NC General Statute 143--215.6E (1), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other document filed or requil-ed to be maintained under this
Article or a rule implementing this article ... shall he Guilty of a Class 2 misdemeanor rl✓hich 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 NP DES Stormwater PerE nit for
the suiDject facility. I am familiRr WI th< the information ccrit2incd in i[his request, and to the Lest of n-iy knowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity:
"Legally Responsible Person:
Title of Lega ly esponsible Pei -son:
*Signatu e: V + �' �/C]� Date:
Print Nance and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
LQ Q G �v� �i15� t l
IMPORTAI`4T NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretat y, treasurer, or vice president, ar a manager that is authorized in
accordance with Part II/, Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the AlCG010000 permit.