NCC205357_NOT Signed Certification_20221103

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, rnaiI the orlyinalsicrned form to the NC DEN/iiLR Stormvkfater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL T HIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU IAAIL DUST BE COMPLETED lrswrlTH AN SIG�!ATu!?E w0T DIGITAL) [40 CFR 122,221
General Permit Certificate of Coverage (COC) No.;
Name of Project:
Per NC General Statute 143-215.6B (1), any person who knowingly makes any false staterne)7t, 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 laud, I certii;1 that:
I, as an authorized representative, hereby request rescission of coverage under the NP pEu Stormwaier Penrnit for
the subject facility. I am familiar with the information contained in this request-, and is ti1-le ihe::t of ! iy know-leege
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity: �.4"�' C� _ _iji) C
*Legally Responsible Persom W �(v __.__
Title of Le, ly esponsible Person: —4—Or—
:rSignatui e: Q%� �� N/C� Date:
Print Name and Title of Signed (only if authorizers' individual signing differs from Legally Responsible Person):
�5k 1 �m�e �iy�5i�� enr
IMPO TArVY 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 Port 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.