NCC205900_NOT Signed Certification_20230504

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, 6th 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.: NC C 2O sg o O
Name of Project: 1�+c-roK SueeLy — MoYOGIt NC,
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: No`1ix- k I e LOPM6--NT G--kOvf L.(C_
*Legally Responsible Person: IN It L-L.SA M R'o NI A-I-Tee
Title of Legally Responsible Person: M AN Al Cv e-(Z
*Signature: ta4l I t �j _`3
Date:
Print Name and Title of Signed (on if authorized individual signing differs from Legally Resp risible Person)
T41 0 M 45 (, 4v RE-LTA f MEMBC--. AakiagA'
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns o 'operates t e
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.