NCC201963_NOT Signed Certification_20230509

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 NOTREO,UEST 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.: A LC_9- CA 9 Cc 3
Name of Project: S6)61Yp — (_off -1
Per NC General Statute 143-215.68(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: PlC� QP t 4= mQ-Sj (.
*Legally Responsible Person: K, R e.t•
Title of Legally Responsible Person: 9 cQc 4 L>C1
*Signature:____62,,L '7 Date: 571/96 --"S
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
/+hi.e ,�r�sn - �CifY\io--,; 4- f\x_ /ass 4c,,-c -f-
*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 8, Item(6)of the NCG010000 permit.
For more information on signatory requirements, see Part IV,Section 8, Item(6)of the NCG010000 permit.