NCC215883_NOT Signed Certification_20231212

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]
Genera[ Permit Certificate of Coverage (COC) No.: IV CC 2, I± ? '3
Name of Project: $cLINY'✓ 5-o1-4-& cL cTR►C 4)0w�R PL rIJ T
Per NC General 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(must match eNOT): STRATA CI- etiGR6-'`i, LUL
*Legally Responsible Person(must match eNOT): M A'Rt.VS \ I 1-1-(JLm
*Title of Legally Responsible Person: .M ANk6 2.
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
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*Signature: F n Z I Date: ` i Z i_3
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* 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.