NCC211495_NOT Signed Certification_20230403

NCGO1 Notice of Termination (NOT) Certification Form
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r 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
—4--- 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(NOT DIGITAL)(40 CFR 122.221/V/
General Permit Certificate of Coverage (COC) No.: L C ( 9 1 c
Name of Project: 5 4ttc ti il;11s £fib-CS tot 31
Per NC General Statute 143-215.68(i),any person who knowingly makes any false statement,representation,or
certification in any application,record,report,plan,or other document filed or required to be maintained under th
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 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. 11
Legally Responsible Organizational Entity: -- �T.CIrr Geirt At e(war
`Legally Responsible Person: 3-A".4.4 5. GGL-
Title of Legally Responsible Person: 0 w[+w
`Signature: j.2 'l s Date: "t/I/ t1 12
Print Name and Title of Signed(only if authorized individual signing differs from Legally Responsible Person):
•IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity,such os o 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 Port IV,Section 8, item(6)of the NCG010000 permit.
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