NCC202160_NOT Signed Certification_20220718

NCG41 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail tlhe original signed form to the NC DEIVIILR Stol-mwater Prograrn at:
Division of Energy, Mineral & Land Resources Stornlwater Program
512 N. Salisbury Street, 6"' Floor
1612 Mail Service Center
Raleigh, PAC 27699-1612
DO NOT MAIL THIS FORIA UNTIL YOUR NOT BEQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETE® %11TH AN ORIGI AL SIGNATURE (NOT DIGITAL) [40 CFP 122.2-2]
General Pel'mit Certificate of Coverage (COC) No.:
Name of Project:
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 NPDE` Stormwater Permit for
thc- subject facility. I am fa'milial,v,dt-h the information coni?,ined in this request, and tC the best of miy knowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity:C�1����-�+rSi-
'regally Responsible Person:
Title of Leg
kSignatu
possible Person:
blo �v'>—
are: 111111-L
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
t2sv4��� U\111f6k�� �V�C__j -,
T lMP0RT'l4r,JT 1V0T'E. This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treosurer; or vice president, or a manager that is outhorized in
accordance with Part A/, Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCG010000 permit.