NCC202988_NOT Signed Certification_20220809

NCG01 Notice of Termination "'NOT) Certification Form
I
D h, e Ictio F1 S:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO iMALTH I$ FOR'-vl, UN-N.L VCUR N'O'T AS 3,H'i 6"9ZViE"W2D AiVD, A PPROWE;.
THE FORNI YOU MAIL MUST BE COMPLETED WITH AN ;PR IGHVA" SiGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.: NCC202988
Name of Project: Town of Columbia —Contract 33-2017 CDBG Project
Per NC General Statute 143-215.6B (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 afine not
to exceed ten thousand dollars ($10, 000).
Under penalty of law, I certify that:
1, 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
*Legally Responsible Person: Jaes
Title of LesKllv RksDonsible Pdrson:
*Signa
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.