NCC203704_NOT Signed Certification_20221117

NCGO1 Notice of Termination (NOT) Certification Form
Print this form, complete, scan and upload tothe electronic NOT (Rescbsion)form.
Then, mail the original m6gnedformtothe NC DEK4LRStnnnwaterProgram at:
Division of Energy, Mineral & Land Resources StormwaterProgram
512N.Salisbury Street, GmFloor
1612Mail Service Center
General Permit Certificate OfCoverage (CO[)NO.:
Name OfProject:
Per N[General Statute 243-215.68(i),any person who knowingly makes onyfalsestatement, representation, m
certification /nany application, record, report, plan, orother docunrentfiledorrequired b»bemaintained under this
Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
Lasanauthorized representative, hereby request rescission ofcoverage under the NPDESStonnwaterPermit for
the subject facility. I am familiar with the information contained in this request, and to the best of my knowledge
and belief, such information istrue, complete, and accurate.
Legally Responsible Organizational Entity: Vk0me", WC-4
�
*Legalk/Responsible Person:
Title of Legally Responsible Pon:
—_'- ~ r '
*Signature:
Print NameondTitle of Signed (only if authorized individual signing differs from Legally Responsible Person):
*
/&VPORTAUVTNO7E/ This form must hesigned bvoresponsible corporate officer that owns oroperates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that isauthorized /n
accordance with Part IV, Section B,Item (6) of theNCGO10000 permit,
For more information onsignatory requirements, see Part IV, Section B, Item (6)ofthe NCGD0000permit.