NCC212885_NOT Signed Certification_20221011

MCG01 Notice of Ter-mination (MOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then. mail the originalsigned form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61" Floor
1612 Mail Service Center
Raleigh, NC 27699.1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED,
THE FORNI YOU MAIL MUST 4E COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFF 122.221
General Permit Certificate of Coverage (COC) No.: niLC,2iZ`��
Name of Project: t1 m 't \4 um 6O
Per NC GenerolStatute 143.215.68 (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report, pion, or other document filed or required to be maintained under this
Article or o rule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include o fine not
to exceed ten thousand dollars ($10,000).
,,, 1 I„ :i +Itv of law, I certify that:
i, ,!�i iiolini:wd i�presenwtrve. hereby request rescission of coverage under the NPDES Stormwater i, rrn!l
t li•_ `uhleL t f0i 1111)'. 1 am f,jm+liai svitl, 0ic information contained in this request, and to the best of my k,t r, li
1111d behei, such information is true, complete, arid
�a-(ccurate.
Legally Responsible Organizational Entity: 0ih` ' `VJ-od�
'Legally Responsible Person: I YWy A1* L VVv\A-J'L rt' L
Title of Legally Responsible Person:
'Signature: �`� Date: I 2
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 6, Item (6f of the NCG010000 permit.
For more information on signatory requirements, see Port IV, 5ection 8, Item (6) of the NCG010000 permit.