NCC202060_NOT Signed Certification_20240212

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
I 512 N.Salisbury Street, 6'' Floor
1612 Mall Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
T Ht. I ORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.22J
General Permit Certificate of Coverage (COC) No.: !V CC 01 O2 0 tD V _
Name of Project: ) Iofe �`1,ee
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Per NC General Statute 143-215.6B(i), any person who knowingly makes any false statement,representation,or
certification in ony 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 o fine not
to exceed ten thousand dollars($10,000).
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Under penalty of law, I certify that:
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I
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. ID 1
Legally Responsible Organizational Entity(must match eNOT): r n. 1--VO r l O r .1-►l e .
*Legally Responsible Person (must match eNOT): 4-7/"Ed ' !4"\ '3"I "'
*Title of Legally Responsible Person: V (.e ?y'ec It Cla.VC4
Print Name&Title of Signed if Au horized Individual Differs from Le�ally Responsible Person:
�ov1a 1A, �kc � As +a Sec✓e tAv-
*Signature: I Date:�.
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* 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 authorised 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 NCGOa0000 permit.