NCC231658_NOT Signed Certification_20230905

NCGO1 Notice of Term nation (NOT) Certification Form
Directions:
Print this form,com riete, scan and upload to the electronic NOT(Rescission) form .
Then, m al the original signed form to the NC DEM LR Storm veeter Program at:
Division of Energy, M neral & Land Resources Storm water Program
512 N. Salisbury Street, 6th Floor
1612 Mal Service Center
Raleigh, NC 27699-1612
DO NOT M AIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU M AIL M UST BE COM PLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.22]
General Perm t Certificate of Coverage (COC) No.: NCC231658
Nam eof Project: Chem serve Tank 109
Per NC General Statute 143-215.6E (i), any person who knowingly m ckes any false statem ent, representation, or
certification in any application, record, report,plan, or other docum ent filed or required to be m dntained under this
Article or a rule im'dem e-lting this Article. . . shall be guilty of a Class 2 m sdem eanor which m cry 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 Storm water Perm t for
the subject facility. I am fam liar with the inform aion contained in this request, and to the best of m yknowledge
and belief, such inform Aion is true, corn iiete, and accurate.
Legally Responsible Organizational Entity(m Est m arch eNOT): Chem Serve Term hal of Wilm ngton, LLC
*Legally Responsible Person (m cst m avch eNOT): M dthew Law
*Title of Legally Responsible Person: Vice President
Print Nam e&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: 09/05/23
* IMPORTANT NOTE: This form m u;t 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 m wager that is authorized in
accordance with Part IV, Section B, Item (6)of the NCG010000 perm t.
Form cre inform ction on signatory requirem sits, see Part IV, Section B, Item (6)of the NCG010000 perm t.
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