NCC212865_NOT Signed Certification_20230629

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.: WLC 2--/Lgc5
Name of Project: LeAc-r•ti
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($10,000).
Under penalty of law, I certify that:
I,as an authorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
the subject facility. I am familiar with the information contained in this request,and to the best of my knowledge
and belief,such information is true,complete,and accurate. `, A, I
Legally Responsible Organizational Entity(must match eNOT): M:Ile. ' M:((er R 1.t4 , Ltc
*Legally Responsible Person(must match eNOT): -b4v;$ frilidleI ?r
*Title of Legally Responsible Person: /1140,6er
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
ter `
*Signature: / • Date: '(v. 7 /23
*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.
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