NCC216315_NOT Signed Certification_20231204

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.: IV I C 2 j 3) S - 20 2- 3
Name of Project: Wc,51-ei.Jc-rer S"-o(ctz Po,d /3€C vi /100�t/ cc•-I04
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. �/
Legally Responsible Organizational Entity(must match eNOT): A rct U C 0 ALA r /'try-e 1 I.G k 1n C
*Legally Responsible Person (must match eNOT): Pc L. 10 I-ran - i n,
*Title of Legally Responsible Person: $evt,.or V-c e Pr-eS, f 4c,,,,A ,O
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
L.Acr y cr,, bn er, v,ro0mePI / /44-VI A 9.e-r
*Signature: V -,--
Date: /Z/c//2023
* 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.