NCC205029_NOT Signed Certification_20221210

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, mmplele, scan and upload tothe electronic NOT (ReWssinn) form.
Then, mail the od.gInafslgned form to the NC nrMIR Slormwater Program at:
DNision of EnerRy, Mineral R land Resources Stormwater Program
512 N. Salisbury street, G'" floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAiL THIS FORM UNTIL YOIIR NOT R►(iWUST IIAs nr r rt ftf VIrN/rr) AND APPROWD,
M FARM you f1UULttA W et: COMPtM VM AN ORIGINAL SIGNATURC INOT tSIGfTAI)140 CFR 122.221
General Permit Certificate of Coverage (COC) No.:,c.�ae�)aq
Name of Project: T 1l 1 lC c1�QC 11Vv
Per NC General Statute 143.225.6E (i), any person who knowingly makes any false statement, representation, or
certification in any application, record, report plan, or ocher 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 a fine not
to exceed ten thousand dollars ($10,000).
Under penalty of taw, I certify that:
I, as an au horized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subject facility. I am familiar % th the information contained in this request, and to the best of my knowledge
and belief, such information is true, complete, and accurate.
Legally Responsible Organizational Entity: 'Lega]fy Responsible Person: � �Y)e
( DD
True of Legally Responsible Person:
'Signature:
/.A
Print (dame and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
' 1101PORTAhT NOTE. This form must be signed by a responsible corporate officer that owns or operates the
consvuction 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 IVCGO10000 permit.
For more information on signatory requirements, see Part iV, Section 0, Item (6) of the NC6010000 permit.