NCC191780_NOT Signed Certification_20230815

NCGO1 Notice of Termination (NOT) Certification Form
Directions:
Print this form,complete,scan and upload to the electronic NOT(Resassroni form
Then,mall the original signed twin tv tl a NC UEMIK Stormwater Program at
Division of Energy,Mineral&Land Resources Sturmwater Program
512 N Salisbury Street,6"Floor
1612 Mai'Service Conte-
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 122.24
General Permit Certificate of Coverage(COC)No.: NCC191780
Name of Project: Cubera Solar LLC
Per NC;rnerol Statute 143 215.6E(ir,on;person who knowingly makes any false statement,reprnsenrntkm,or
certification in ony application,record,report,plan,or other document filed or required to be maintained under th,s
Article or o rule implementing this Article...shclr be guilty of c Class 2 misdemeanor which may include a fine no:
to exceed ten thousand dollars($1C,CCO).
tinder penalty of law,I certify that:
I.as an authorized representative,hereby request rescission of coverage under the NPCES Stcrntwater 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,anc accurate.
Legally Responsible Organizational Entity;must match eNOTI:Pine Gate Renewables
•Legally Responsible Person(must match eNOT): Brian Studenka
•Title of Legally Responsible Person: Vice President Owner Engineering
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
/1
'Signature x' 8l14l23L �iiYii22/%+ --Date: -
IMPORTANT NOTE; This form most be signed by a responsible corporate officer that owns or operates the
r»nsVucrinn activity,such as u president,secretory,treosurer,or vice president,or a monoger that Is authorized in
accordance with Port IV,Section B,item r6)of the.N000:O00U permit.
Inr more information on sigrwtory requirements,see Port Il,Section B,Item(6)of the NC(01(Y) O permit.