NCC200360_NOT Signed Certification_20230502

NCGO1 Notice of Termination T) 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, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO N•T MARL THIS FORM UNTOL YOUR NOT REQUEST HAS BEEN REVOEWE D AHD APPROVED,
THE FORM YOU MARL MUST BE COMPLETED%MT1 H AN ORIGINAL SOGNATURE i OOU l LU E . 22.2.2y
General Permit Certificate of Coverage (COC) No.: AiC(�.20034A
Name of Project: 1 hutile*AcAOS
QVA,staSPR.
Per NC General Statute 143-215.6E(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 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:
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: CAP' R2\ to1;1 1115046S L C
*Legally Responsible Person: J/DSO yk) Y" eRk bW
Title of Legally Responsible Perso IVVrIVA5efi.
*Signature: Date: 6'.1.-41-3
Print Name and Title of Signed my 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 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.