NCC204481_NOT Signed Certification_20231102

NCGO t Notice of Termination ( Not ) Cprt Ificat ion Form
Directions:
Print this fol ompiete, st upload to the tgl.rtrt►tilt Nt t I (ItaicIi*inn) form.
Moo, ihc' c►►tul►rcrl algneti lotto to lilt? Nt I )I MI It 'dot Itlwrllc't I'iu t hilt ,it
Division of I not Ky, Mlnti ril R I Atld ROsotii t'tiq Stut tttwott+t I't ()w call
'• I ) N, Sdik tttt y tits tvitt, t►ih I loot
I t► 12 Mall StirvIct Conte,
Raleigh, NC 176994612
no NO1 MAIL Ii11S i ORM UNTIL. YOUR NOT RI (ZUI.Si IlAs Di c N in vie WID AND APPROVED.
TtiefORM YOU MAtt;MUST tit ( 0MPh t 1 in WITH AN ORIGiNA1-SIciNATtIltF (NeWITRIMMIIM ittla
`t'i rule Certificate , 'r , ' (Co( i , , NCC2U448 I
General ertificatf of Cc vt; rage ( 1 _
Nome of l t ��it t, t .
Lightning MCClonn
Per NC General Statute 143415,6v (I), any person who knc)wlntjjl►- tit(rte meat, representation, or
cent ficationt in any application, record, report; plan, or other door►trr,r filed or r rii(11n el ( ) be maintained under thlc
Article or a rue implementing this Article , , , shall be guilty of a Class 2 r►►icdtbmei 7nrir 1,vhlch may include (► f itu' not
to exceed tent thousand dollars ($10,000),
Under penalty of law, I certify that:
I, is 1n authorized 1 c`pi 0".c'i1t,1tivt', hot c`Ihy Ft'titte% .t I t'SCiscion of COVot',lt;c` wide' tho NIII )1aS Storm water Permit for
the subject facility, I ,till t,lt►illi,tt with the into' motion cut I Iti thy•. I tIth`•,t , to the` hit of my ktlr,►wlrtihc'
and belief, Stich illfornt ttion is tripe, coniplt'tt', anti acfllr,ltt',
' �t �,lt ltic�tl,ll I Iltlt Illlltit match c'Nt.li ; Mustard Sochi ('Itc':;tc9lhold, LLC
Legally Rusponsiblc l h flit y ( 1
B1.09ci011
°legally Responsible Person (must match eN01 ):
*Title of Legally Responsible Person: President
g Y p
Print Name & Title of Signed if Authorized Individual Differs from legally Responsible Person:
`Signature; (in/ Date: //J23
• IMPORTANT NOTE: This form must be Signed by ►e%ponsiblc corporate office► that owns or operates the
construction activity, such as a president, secrc•ttii v, treasurer, or vice president, or (1 ►tltrrtacrer that is authorized In
accordance with Port IV, Section 0, item (6) of the NCGO10000 permit,
For more information on signatory requirements, see mart IV, Section il, Item (6) of the N ()NcGot0000 permit,