NCC205608_NOT Signed Certification_20240116

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, 6t 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 IAl1 l i OS1''1!t' b W!"I~M AN ORIGINAL SIGNATURE(NOT DIGITAL)141)CFR 122.22j
General Permit Certificate of Coverage (COC) No.: N CC 20 5608
Name of Project: CA N T St E
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: Lt giv4 CvrStr tiCte V^-)
*Legally Responsible Person: iw,'LC-€'4b L-fr1'
Title of Legally Resp sible Person: ptZeSi n t M'1
*Signature: _ Date: / -/H-21?
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 8, item(6)of the NCG010000 permit.