NCC202072_NOT Signed Certification_20221209

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this dorm, comptcW. scan and upload to the electronic NOT (Rescission) forme,
Then, mail the pr! Inof signed form to the K OEMLR Stormwater Program at:
p; Oon of Energy, Mloeral & Land Resources Stormwater Program
512 N. Salisbury Street, 611 Floor
1612 Mail Service Center
Raleigh, NC 276"-1612 - - -
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED,
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGt1ATURE (NOT DIGITAL) 1413 CFR 122.22]
General Permit Certificate: of Coverage (CDC) No.. N o t-D 1-L
Name of Project: iPl lif ,-%c- -r r,)rt-r C-.As U 49 Z` i - i 4 q5 lJ,4iv rcl►t G05 Pe /V -11-
✓�w Ear
Per NC General Statute 143-215- 6B (i), ony person who knowiny ty makes any Joke Stote-eni, representation. or
certification in Gny application, record, report, plan, ar other document freed or required to be maintained under this
Article or o rule implementing this Article ... shalt be guilry of a Class 1 misdemeanor which ropy include o frrne not
to exceed ten thausond doftars
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPOES Stormwater Permit for
the subject facility. I am familiar with the information contai ngd in this request, and to the best of my knowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity: _ Fei) t f*S Agv,-AL- C�,A.S - WC.
'Legally Responsible Person: Q +t XX-5
Tide of Legally Res cnsWe Person: PLOD Ccf 0"4 "At),-k-
'Signature• _ �1~' r p
_Oats:
Print Name and Title of Signed (only if authorized individual signrnp differs from legally Responsible person),
INrPORTAIvi NOTEr This form must he signed by a responSibfe corporate officer that owns ar oAerates the
activity, such of orpresident; Secrefary, treasurer, CIr vice President. Ora manager that is authorized in
atcordon<P with Pprd IV, Section 8, Item (6) of the NCG0100 0 permit.
for me rn tot .,,Ar:, -- ..w--------- - -°- _
, Item (G) of the NCrOIWW permit.