NCC205324_NOT Signed Certification_20220829

NCG01 Notice of Termination (NOT) Certification Form
Directions:
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, 5th 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 ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.:
Name of Project:
10233 Rodney Street
NCC205324
Per NC General Statute 143-215.6E fi), 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 Articie ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars f$10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit far
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:
Rodney Street, LLC
*Legally Responsible Person: Lorin Stiefel
Title of Legally Responsible Person: _Manager
*Signature: v`. 6 IVJ
Date: l r L(, ! Z ?—
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
(t il0,(t c= _—
* IMPORTANT" NOTE. This form must be signed 6y 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, ±rem (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, item (6) of the NCGO10000 permit.