NCC204647_NOT Signed Certification_20221012

NCGa1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload -to the electronic NOT (Rescission) form.
Then, mail the orig4nalsrgrledform to the NC DEI\/ILR Stormwater Program at:
Division of Energy, Minerai & Land Resources Stormwater Program
512 N. Salisbury Street, Gt" Floor
1612 fviail Service Center
Raleigh, NC 27699-16" 2
DO NOT MAII T HIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE CONIFLETED VYITH AN ORIGINAL SIGNATURE (NOT € IGIi'AL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) NN o.: cy vq Y f`r
Name of Project:
-WAS_`11
1G � IS
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 o 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 coverage under the NPDES Stormwater Pen-n'lt for
the SUbjeCt facility. I am fla III iliGl with the inform?`: on container` in this re,,quest, and t0 ..he hest of Iliy knowledge
and belief, such information is trr.Ie, complete, and accurate.
Legally Responsible Organizational Entity:
"Legally Responsible Person:
Title of
*Signatu
sponsible Person:
: i�) I I I N aZ
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
IMPORTANT ANT 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 NCG010000 permit.