NCC205504_NOT Signed Certification_20240103

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 MUSTI BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: NG C -' `)13 014
Name of Project: —rig & r ✓c, (e (SD l�✓CG ��rf
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): I ' -?p 6 "SfKC�-1� (PLC
*Legally Responsible Person (must match eNOT): A 1 - I O_V'T
*Title of Legally Responsible Person: {rr\ l
Print Name&Title of Signed if Authorized Individual Differs from Legall Responsible Person:
*Signature: LA4 • `Noun-{ Date: ) A 2-4-
* 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, l em(6)of the NCG010000 permit.