NCC214289_NOT Signed Certification_20221107

NCG01 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upioad to the electronic NOT (Rescission) form,
Then, mall the original signed form to the NC DEMLR Stu rmwater Program at:
Division of Energy, Mineral & Land Resources Stormwater ProUam
512 N. Salisbury Street, 6"' floor
1612 Mail Service Center
Raleigh, NC 276139-1612
❑O NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS SEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGiTAL1 [40 CFR 122.221
General Permit Certificate of Coverage (CDC) No.:
Name of Project: L-(-e_c d 1'noaR- �\NAVJ�R-
N(-(--�IIa8 J
Per NC General Statute 143.215.66 fi), any person who knowingly makes any false srotemenr, representation, or
certification in any applicotian, record, report, plan, or other document filed or required to be maintained under this
Article or a rule implementing rhis Article ... shah be guilty of o Class 2 misdemeanor which may include a fine not
rQ exceed ten thousand donors ($I0,000).
Lander penalty -of taw, I certify drat:
I, as an authorized representative, hereby request rescission of coverage tinder the NPOES 5tormwater Permit for
the sulsject facility. I arty famillar with the Information con taitie d in this request, anti to the best of my know [edge
and belief, such information is true, complete, aiid accurate.
Legally Responsible Organizational Entity: , fd�i ��i � •`�� �� � d.C3 -�-'
"Legally Responsible Person:
Title of Legally Responsible Person: r'W 1y'1~-'-
'Signature: Q..' Date: I
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 nctiv4, such as o president, secretory, tre❑surer, or vice president, or a manager that is authorized in
accordance with Part IV, Section 8, ttem (61 of the NCGO100W permit.
For more information on signatory requirements, see Port iV, Suction 8, Item f5) of the NCG0J0000 permit.