NCC204876_NOT Signed Certification_20220930

NCGo1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upIcad to the electronic NOT (Rescission) Torm,
Then, mail the originalsignedform to the NC DFiVILR Storm water Program at:
Division of Energy, Mineral & Land Resources Stormv+ater Program
512 N. Salisbury Street, 6"' Floor
1612 [Vail Service Center
Raleigh, i�C 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUESTHAS IAS BEEN REVIEWED AND APPROVED,
THE FORM YOU MAIL MUST BE COMPLETED VU1ITH AN ORIGI14AL SIGNATURE (NOT DIGITAL) [40 CPR 122.221
Genera( Permit Certificate of Coverage (COC) No.:
Name of Project:
Per NC General Statute 143-215.6B (i), any person who knowingly makes any false sratement, 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 v✓hich may include a fine not
to exceed "ten thousand dollars ($10,000).
Under penalty aT law, I cet-t IRIf that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Pernlit for
The subject - facility. i am raniiiiar v�;iti) i-,e inroriylation contained in -]-,is r-Lquo --, and to the I-es� of il"I knowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity: 44-cQXNAXk�p— j i I
*Legally Responsible Person:1 l W
Title of Leg
*Signatu
nonsible Person:
Print Name and Title of Signed (only if authorizes' individual signing differs from Legally Responsible Person):
Lzilt CC) (Wes 1Diut"0(\ '�ArC[C(kft_
IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasure), or vice president, or o manager that is authorized in
accordance with Part IV, Section B, Item (6) of the NCG010000 permit.
For more information on signatory requirerrrents, see Part IV, Section B, Item (6) of the NCG010000 permit.