NCC203316_NOT Signed Certification_20231129

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.: N C C, a 0 33 1 6
Name of Project: Tfav,6 (1Ais1..%., tr S ,,Nob •J.5 oN. - Lao 3
lgal 1:'ctbo4. tia,, acOtlrlin rv.c. 21 603
Per NC Genera!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.
Legally Responsible Organizational Entity(must match eNOT):
*Legally Responsible Person (must match eNOT): D P+.i c\ 3 p N r.-.t a el,.
*Title of Legally Responsible Person: 0 w w 4..e.
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
0*Signature: (--- C J/ Date: II 1 2-4 1 a-O23
*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.
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