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HomeMy WebLinkAboutNCC211872_NOT Signed Certification_20230516 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,6tn 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.:VCAkto 7 2 Name of Project: V2 Ja A> 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: IDIOaStsiA ('Arty iv *Legally Responsible Person: Cs6A ill• (Ka SS Title of Legally Responsible Person sr€kv. f` *Signature 1 i !e—` - -- -- Date: 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. D_E Q 7