NCC191026_NOT Signed Certification_20220804

NCGO1 Notice of Termination (NOT) Certification Form
Directions.a
Print this form, complete, scan and upload to the electronic NET (Rescission) form.
Then, maid the original signed form to the NC DE[UILR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street,. 6th 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
MUST BE COMPLETED WITH AN pRIGINAL SI.GNAT:URE SNOT
Di61TAlj [40 CFR 122,12]
General Permit Certificate of Coverage (COC) No.: I� `�� � `--`� � � � Z k,;r
Name of Project:
1E C----- I �� ( 7&� C.- C�
Per NC General Statute 143-215.68 (i), any person who knowingly makes any false statement-, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article or a rule imp lem en ting i-hrs Article .. , shall b e guilty of a Gass 2 misdemeanor which miry include a fine not
to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
11, 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. ���—f ���
*Legally Responsible Person: � ���~- ]=
Title of legally Respp
0
*Signature..
on:
Date.
Print Name and Title of SEgned (only if aurhorized individual signing differs from Legally Responsible Personj:
* JMPQRT►dI1VT Na7F: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, i�r'easurer, ar vice president, or a manager that is authorized in
accordance with Part lU, Section B, item (6) of the lVCG010004 permit.
For more information on signatory requirements, see Part IV, Section B, fiem (6) of the NCGO10000 permit.