NCC205766_NOT Signed Certification_20230118

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6"' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE INOT DIGrrAL} [40 CFR 122.72I
General Permit Certificate of Coverage (CDC) No.: N CC 2_o5
Name of Project: -%'iERNC.R S C,LurS "-r 5-b L
Per NC General5totute 14.3-215,68 (i), any person who knowingly makes any folse statement, 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 .. , shad be guilty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars (S10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit 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 is true, complete, and accurate.
Legally Responsible Organizational Entity: I'CHPfLIC� C.�*�S uG'rls:.f C-C" .
'Legally Responsible Person: W 1"(A r1 %MA$U L.a 5+Z
Title of Legally Responsible. Pp<so)N f'i� 10 CN T-
'Signature:
Date: IZ 2- Z, I-t
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
,N IL _ 1 A� f2om p� k to s lt_ - �' [� PIt�St �j£,+�r c f aPEr..'n Icr►r�
• IMPORTANT NOTE. This form must be signed by a responsible corporate officer that owns or operates the
construction actrviM such as a president, secretary, treasurer, or vice president or a manager that is authorized in
accordance with Part IV, Section 8. Item (6) of the NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6j of the NC6010000 permit.