NCC203664_NOT Signed Certification_20230816

NCGO1 Notice r i i n (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 SIGNATURET ,� [NOT DIGITAL)[40 CFR 122.22)
General Permit Certificate of Coverage (COC) No.: f v C kV 6 6 ci
Name of Project: Lcyl- G ( of
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: / o✓t� l e ( 1�0."f '=c(,4 Sk. L L
*Legally Responsible Person: LC%Jr y Vt.
Title of Legally Responsi P son: Pc-e6 t CL _
*Signature: Date: (G��
Print Name and Title o igned (onl if authorize individual signing differs from Legally Responsible Person):
*IMPORTANT NOTE: This form must be signed b 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.
II.;