NCC203084_NOT Signed Certification_20230831

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) 140 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: P(CLz.C3o4 1
Name of Project: TI-1 VL S i74/
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.
LLG
Legally Responsible Organizational Entity(must match eNOT): R6ALc'R(.3P6C )65Ai?Z ,J6c4s Li
*Legally Responsible Person (must match eNOT): (7)ATT SG1-IRRF
*Title of Legally Responsible Person: (31.✓NEt .
Print Name &Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: g/242123
* 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 8, Item (6)of the NCG010000 permit.