NCC203609_NOT Signed Certification_20230807

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.: k,(C G 203 GO 9
Name of Project: 3 'I? 4k( CAmefisc ti t /e 6, S7)476-
-fia AE* / 76M- l TL1X.S , S7791-61VILW- NC
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(must match eNOT): 140Nlika . S4JF- 4
*Legally Responsible Person(must match eNOT): .I. A/NI S /Iko77
*Title of Legally Responsible Person: ''f24-7Q
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature r �! �%' Date:
* 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.