NCC215787_NOT Signed Certification_20230215

NCGOI Notice of Termination (NOT) Certification Form
Directions:
Print this. form,. complete, scan and upload to the electronic NOT (Rescission y farm.
Then,mail the origiinalsignedform.to.the NC DEMLRStorrrswater Program at:
Division of Energy, Mineral &. Land Resources Stormwater Program
.512 N. Salisbury Street,.6th Floor
1612 Mall Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REV[EVIED AND APPROVED.
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General Permit Certificate of Coverage (COC) No..
Name of Project: td`trsAn, Lo
PJC- �715-7k7
Per NC General Statute 143-215.6E (i), any person who knowingly makes.any folse statement, representation, or
certification in any application,. record, report, plan, or other .documen.t filed or required to lie maintained under.this
Article or a rule implementing this Article . shall be.guilty of o Class 2. misdemeanor which may include a fine not
to exceed ten thousand dollars ($.10,000).
Under penalty of law, 1 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 th:e best of my knowledgo.
and belief, such information is true, carnp.lete, and accurate,
Legally Responsible Organizational Entity:
*Legally Responsible Person: 1d iJ �rti�
Title of Legally Responsible Person:.�ti
*S.ignature,
Date: n I )b j-W21
Print Name and Titleof`a fined (only if authorized individual signing differs froi-n Legally Responsible Person):
* IMPORTANT NOTE. This forma must be signed by a responsibie corporate officer that owns or operates the
construction activity;. such as a president,. secretary, treasurer, or vicepresident, or a manager that is authorized in
accordance with .Part 1tI,.Section B, Item (6) of the NCG0I0000 permit.
I"or.rnore information on signatory requirements,. see Part IV, Section B, Item (6) of the NCG0.10000 permit.