NCC203082_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 SIGNATURE2 (NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: Ncc ao 0.32
Name of Project: 1 %i7W SV2dAeksi ' \ Mv1&x l-d+S
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):)�• \--\o \�/a' Vv•
*Legally Responsible Person (must matchtc eNOT): S,)S&T Ar\a tvson
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*Title of Legally Responsible Person: IV \(Y ) pmc 1eChr\iC 4CA ettiY0 nL 1rws e
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Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
jess;c14\tNyf Div. SirnnwoACc C b 1nolnt-t S CA(61 )r1L
*Signature: Date: 1 `2_3
* 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 8, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NCG010000 permit.