NCC214153_NOT Signed Certification_20240205

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 122.221
General Permit Certificate of Coverage (COC) No.: ill(-C- 1 `l-I 6-3
Name of Project: (.7i^e..,e•� f gf i 0 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): G 0 Prcp.e.-`' / ii, L_L.c_
*Legally Responsible Person(must match eNOT): i d, / 13-urY‘e_4-'
*Title of Legally Responsible Person: Pre-5
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: 2_3 oZ 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 1V,Section B,Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section 8, Item(6)of the NCG010000 permit.