NCC230642_NOT Signed Certification_20231102

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`h 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.: I�1CC230(042..
Name of Project: Fi�Pn1L- 'DLLs-lam `'QZt
Per NC Genera!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: C. cPCi. (4.31 'W` ‘'"- —!
*Legally Responsible Person: €N .AYE V W
Title of Legal! onsible Person: M.etika i2
*
Signature: Date: 1‘1'z.l'7pZ..-Ic
Print Name and Title of Sign (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.