NCC201013_NOT Signed Certification_20230502

NCGO1 Notice of Termination (NOT) Certificg ti 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 POT MAIL ThIS FORM UNTOiL YOUR NOT REQUEST FAS BEEN REVIEWED ARID APPROVED.
JL YOU MAIL MUST BE COMPLETED WIU O-1 AN OROOIRALL SOGicATURE(NOT DIGITAL)) (4i CFR 122.22]
General Permit Certificate of Coverage (COC) No.: "C„?o I b/ 3
Name of Project: inptiv,5 Vi .,oR, -Ca.Qt1-1CAI „ ,5 3I.f//o Lars 1 �3s
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: Coo k �t 1- � f�� L (_C,
*Legally Responsible Person: J PrSolii Ptbrrefit)
Title of Legally Responsible Perso . AnA'VUfleJ .
*Signature: � Date: -001
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 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.