NCC202725_NOT Signed Certification_20230621

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NCGO1 Notice of Termination (NOT) Certification Form
J — - -_ 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: .L--
Division of Energy, Mineral & Land Resources Stormwater Program imoks
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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 MAR. MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.: 1e71-Z5
Name of Project: 1:F53 r{5 &\is c 3 , 1acnerOn "Track IkAceipLo `d
Per NC General Statute 143-215.6B (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). i
1
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 (must match eNOT): KC pa k.--\01\k0_,5 i PLC
*Legally Responsible Person (must match eNOT): J7 l 9A.6-er cL.
Title of Legally Responsible Person:
rf ('o,S-t-tudi Or1 S . 1,u,S-f-
Print Name & Title of Signed if Authorized Individual Differs from Legally Responsible Person:
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gnature• ' • '
Date: (Q ('Z I 1,3
lPORTANT NOTE: This form must be signed by a responsible corporate officer
struction activity, such as a president secretary, treasurer, or vice pent that owns or operates the
)rdance with Part IV, Section B, Item (6) of the NCG010000 permit. dent, or a manager that is authorized in
more information on signatory requirement
s, see Part IV, Section B, Item (6) of the NCG010000 permit.