NCC216497_NOT Signed Certification_20230405

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/ (NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: N C C a� C�G l /
. s cyq
Name of Project: wa I l'
Per NC General Statute 143-215.68(i), any person who knowingly makes any false statement, represe
ntation,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.. .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:
ission of
ES Stormwater Permit for
a uaectfacfacility.
authorized representative,familiar w threby request the nformationccontainedoin this req est,the
and to thebest f my knowledge
the subject facility. I am
and belief, such information is true,complete,and accurate.
/4 JAI&
Legally Responsible Organization I Entity:
*Legally Responsible Person: �►"► id
r`t
614
Title of Legally Responsible Person: /V4.1
I Date:
*Signature: �—
Print Name and Tie Signed(only if authorized individual signing differs from Legally Res onsi e Person):
*IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction 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 NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.