NCC201035_NOT Signed Certification_20230420

NCGO1 Notice of Termination ( NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form,
then, mall the original signed farm to tie NC DE MLR Storrnwater program at
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street. 6" Floor
1612 Mail Service Center
Rale gti, NC 2764a-1612 -
DO Nt)i MAIL THIS l ORM U►r i it. YOUR NOT RELQUqST HAS SEEN RFVIEWED AND APPROVED
THE FORM YOU MAIL MUST Ili COMPLETED WITH art OptGlNAL 5KINATURt IND t OIWT*LI 14O CFA 112.22j
General Permit Certificate of Coverage (COC) No.: Ai (. Z 0 i 0 3o j
.� F & f'4411.'e. •) � r- ST �A fName of Pro eft. � � �
1
Per NC Genera!Stature 143•21S.6B (i), and person who knowingly makes any false statement, representation, or
certification in any applicaVon, record, ierort, plan, or other document filed or required to be maintained under this
Article or a rule implementing this Article , shall be guilty o/ a Class 2 misdemeanor which may rnctude a fine not
to exceed ten thousand dollars ($10,000)
Under pens:ty Cif law. I certify that:
I, as an authorized representative. Hereby request resttsfron of coverage under the NPDES Stormwater Permit for
t'e subje-t fatuity. I a^r familiar with the information contained sr this request, and to the beat of my knowledge
and belief, such information Is tr.,e complete, and accurate
Legally Responsible 0 alI:ational Entity; (so h Film I L 7 PPtetg--/ 1 E1 t L.e
'Legally Respo ible ersbn: n tz i, , .4,- 1 "4-
Title of Le Iy 4 oFf`s-ble Person: 104'd >ti Fit S Li f-E" nit=A f v r�
'Signa:ure Date: 7/-1-64-0"1--2
Prim 'tame and Title of Signed (only if authorized ,ndvlcIuai signing differs from Legally Responsible Person).
' IMPORTANT NOTE: This form must be signed by a retpans,bfe corporate officer that owns or operates the
construction ocrsvo. such as a president, secretory, treasurer, or vice president, or a manager that is authorized in
accordance with Part V. Section it Item (6) of the NCG0i0000 perm'r.
For more information on ssgnarory reaulrements, see Part IV. Section a item (6) of the NCG 010YQ0 permit.