HomeMy WebLinkAboutNCC215864_NOT Signed Certification_20231101 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.: 11-1
Name of Project VO\�we�t' i� pZ l0lS�b"2'
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 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.
1\ r I
Legally Responsible Organizational Entity: ��' 1 �� �C J c5C �� i\1Q 'L1 ._
*Legally Responsible Person: L.Q.Ce>\VC COM\fw
Title of Lega 'esponsible Person: \J ��g rk
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*Signatu � ,Q/�
U-' �� Date: t 1 OI (2OZ3
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* 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 B, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, item (6)of the NCG010000 permit.