NCC205788_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 MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22)
General Permit Certificate of Coverage (COC) No.: (UCC 2 OS 7 82
Name of Project: A A; Ali 2-
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.cu
Legally Responsible Organizational Entity: / 16-;7_5'/1� / " ,7/ Hde-CS
*Legally Responsible Perso • )74-ber'�` Pav l/S
Title of Legally Res le Pers 01120eci
*Signature: js Date: l 3
174
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
*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 8, Item (6)of the NCG010000 permit.
For more information on signatory requirements, see Part IV,Section B, Item (6)of the NCG010000 permit.