NCC230936_NOT Signed Certification_20240124

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,6111 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 122.22j
General Permit Certificate of Coverage (COC) No : /l o -/?3 0
Name of Project: 111907--� WQ�ICl/1 VT'f5,-�L Wa4e�'i ✓>e___
Per NC General Statute 143-215.6B(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): --P.g, 00419 v1 ) 1 C— •
*Legally Responsible Person(must match eNOT): 47). --A bei 1" 5 I/te 1 70---1
*Title of Legally Responsible Person: . Ce ‘Pee 5 tr c►e,----►
Print Name&Title of Signed if Authorized Individual
Differs from Legally Responsible Person:
�D�1a 1,/ A: ke ✓1 AS5:5- ,'1 dJecf,e --c.0
*Signature: � Pif Date: ( Z4 z
*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.