NCC214347_NOT Signed Certification_20220802

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Prin`i this form, complete, scan and upload to thee I ectronic NOT (Rescission) form,
Then, mail the original signed form to -the NC DIK11R Stormv~rater Program at:
Division of Energy, Mineral & Land Resources Storimtildater 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 FOFE€1'i YOU MAIL P4UST BE COMPLETED Erg.+ITH AN ORIGINAL- SIGNATURE (NOT DIGITAL) [40 CFR 12212]
General Permit Certificate of Coverage (COC) No.: C�,ZI
Name of Project:
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false statement, representation, or
certificotion 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 he guilty of a Class .2 misdemeanor a✓hick may include o fine not
to exceed ten thousand dollars (10,000).
Under penaiLy oL Iavd, i certify Lhati:
I, as an authorized representative, hereby r-equest rescission of coverage under the NPDES Stormwater Perimit for
the subject facility, I am "ialmlliar with the infori-nation contained lid this i"equest, and to _he cf knowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity:
*Legally Responsible Person:
Title of Lega ly esponsible Person: TUk�cx\ �S
I`Signatu
)� �­o b, W6
A
in
� r r'-
Date:
Print Name and Title of Signed (only if authorizes' individual signing differs from Legally Responsible Person):
1l417p£3RTANT NOTE: This form must be signed by o 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 NCG010000 permit.