NCC215361_NOT Signed Certification_20220913

NCGO1 Notice of rermi>I atim (NOT) Certification Form
Direction%:
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I►tI N01 MAIL THIS FORM t1NI11 YOUR No] lil cull SI 11A% III I,N I0 V11 WrD AND APPROVED.
I 111 1 ORM YOU MAIL MUST III CUMI'I r TI I1 WI III AN 0111GINAL SIGNAlu4tli (NOT DIGITAL)140 CFR 122,221
General I'enitil certificate nl C't►vt'r& (CQC) No.: ,!
Narllo of I'1 n(t,t r: � l 6 6 i up o k ti
Per NC General Statute 143-2J5.68 (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 0uilty of a Class 2 misdemennor which may Include a fine not
to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of rownage under t1w NPOES Stormwater Permit for
the subject (acllitY. I am tam War with the Information rontoIned In Ihls ravlum1, and tothe best of my knowledge
and belief, such Information Is true, complete,
,aand accivate.
Legally Responsible Organizational Intity: l�,dob�Z � 0k541-4 cf j
"Legally Responsible Person:
Title of Legally Responsible Person:
'Signature:
.L3.Z
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 mortager that is authorized In
accordance with Part IV, Section 8, Item (6) of the NCG010000 permit.
For more Information on signatory requirements, see Part IV, Section 9, Item (6) of the NCG010000 permit.