NCC202143_NOT Signed Certification_20230703

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.: rvccaoalLi 3
Name of Project: A N N A NCI Q. P h A.S e
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.
Legally Responsible Organizational Entity(must match eNOT): d --6'rl 0 fr12s A e c , LLC
*Legally Responsible Person (must match eNOT): ( 1 1 M )L1 C' Li A nJ A G A ( S
*Title of Legally Responsible Person: PC-L S\ al Q N...)
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
p12oDt&c.rto+.i fte_ AbAtits' L-ks ,4
*signature: Date: , 3 -
* 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.