NCC203294_NOT Signed Certification_20230815

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.: /VC c a 0 3a 9 4. a00. 3
Name of Project: R-c.A lictuflol
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. ( r
Legally Responsible Organizational Entity: /4d s tioMCGS , e c C. Lc
*Legally Responsible Person: iC ��j rsa Ili an ;Ka,
Title of Legally Responsible Person: ke.5 nu\ (1'•1 o.r1 ot, e r
e'C.*Signature: TQu.4-`_ Date: V15`e23
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
cr.i..) Ad APIS biomes Aec i.L4C in
*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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