NCC204604_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.: iJC JO(-{ E 0 -1
Name of Project: Fc),y�-Ht,U11IP DOT n�.}-c.r Loop Lc awv Yo•rc)
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(must match eNOT): PI e�J ►/��" ���"�.��` S
*Legally Responsible Person (must match eNOT): �1L7Sf L► \"kc°( .wvt ft�
*Title of Legally Responsible Person: Pcc jfL NIL-0ul(A.yr:r
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: �. Date: _l- 1 aQ D,3
*IMPO• ► 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.