NCC202050_NOT Signed Certification_20230901

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.: A)C.J C e2c) oC 050
Name of Project: I G.yC'+ UtU () -er Lvc;pf LiA65 C n6vs.d 1!i`,tr.. (rPse,tatAlion
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. i `
Legally Responsible Organizational Entity(must match eNOT): I-��GC � 1J .t'u1 GG�S
*Legally Responsible Person (must match eNOT): JOSe.p\" He.444,,Y-
*Title of Legally Responsible Person: i''tc�coje,c.A.- (�r.�✓�t 1ei
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: Ci ` I
* IMPORT•NT NOT-. This form must be sign d by a responsible corporate officer that owns or operates the
constructi.n acti ,such as a president, secretary, treasurer,or vice president, or a manager that is authorized in
accordance 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.