NCC214585_NOT Signed Certification_20220802

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and unload to the electronic NOT (Rescission) form,
Then, mail the oricginalsianed foi-m to the IBC DEMM Storm dater- Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6"' Floor
1612 Mail Service Center
Raleigh, IBC 27699-1612
DO NOT MAI>! THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED,
THE FORM YOU MAIL MUST BE CONIFLETED WITH AN ORIGIK61 SIGNATURE (NOT DIGITAL) [40 CFR 12.2.221
General Permit Certificate of Coverage (COC) No.: I\ ] l 5%5
Name of Project:
V5 Run
Per NC Genera! Statute 143-215.6B (i), any person who knowingly nukes any false statement, representation, or
certification in any application, record, report, plan, or other document fled or required to be maintained under this
Article or a rule implementing this Article. shall he guilty of a Class 2 misdemeanor vehich tray include o fine not
to exceed ten thousand dollars ($10,000).
Under penalty of laud, I certify that:
I, as an authorised representative, hereby request rescission of coverage under the NP DES Storrn%vater Pen -nit for
the subject fuCllily. I aril famillar with Mlle inforrna- iCn Conn-F-i led in tl"!ls reg3uest, ails -i�:s tree 1 �e.st of my knovvledge
and belief, such information is tare, complete, and accurate.
Legally Responsible Organizational Entity:
*Legally Responsible Person:_ W --
Title of Legg iy esponsible Person:
*Signatu
Bate: lq.�
Print Larne and Title of Signed (only if authorized individual sinning differs from legally Responsible Person);
t oc._-aif, Cova e- 'bvtstun WfNt&rxA _
IMPORTANT NOTE: 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 (5) of the IVCGO10000 permit.