NCC203425_NOT Signed Certification_20230919

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, 6"'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 122.221
General Permit Certificate of Coverage (COC) No.: NC C 2 O 3 ' 2 5-
Name of Project: ic/AL Kf,e qM v
Per NC General Statute 143-215.68(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 o Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars($10,000).
Under penalty of law, I certify than
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 ��jj
Legally Responsible Organizational Entity(must match eNOT): 49, cv.420°jy$04/'f LL C.
'Legally Responsible Person (must match eNOT): IN/Z. Si7.6290Y—Cciel/
'Title of Legally Responsible Person: /y2ffas'E','
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
•Signatur "-?ki — Date: 7- ie • 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,secretory, treasurer, or vice president, or a manoger that is authorized in
accordance with Part IV. Section 8, Item(6)of the NCG010000 permit
For more information on signatory requirements, see Port IV.Section 8, Item(6)of the NCG010000 permit