NCC213791_NOT Signed Certification_20230526

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 wrP-I AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.: M C,C,tik S 4 I
Name of Project: Chc\vel CctGke_ Lok
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:UllnIf CS+01YI
*Legally Responsible Person: Bonn �UXV( nO\
Title of Legally Res le erson: pY�S1C�
*Signature: /PP' Date: o ( LZ/23
Print Name nd Title of Signed (only i 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.