NCC202730_NOT Signed Certification_20230710

NCGO1 Notice of Termination (NOT) Certifi ° 6,co 1,r';©t-nrip
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
General Permit Certificate of Coverage (COC) No.: ? l7 b
Name of Project o ! 9 0 " oaf
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, "I",_A ,-11� a•,, n,_�.11� ,Zr���,_I.,,. ,_} ,r,}�,. i i c
*Legally Responsible Person: i 1 ... „l
Title of Legally Responsible Person: •'10.., �,
*Signature: fI
"; Date: •yhj
Print Name and Title of Signed(only if authorized individual signing differs from Legally Responsible Person):
( k(A t L f v13116 w`7421c-5 D
*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 8, Item(6)of the NCG010000 permit.
For more Information on signatory requirements,see Part IV,Section B,Item(6)of the NCGO10000 permit.