HomeMy WebLinkAboutNCC204210_NOT Signed Certification_20240312 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.: tJcc ac4 al n
Name of Project: P r\ OPOZAfTE
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: OU VtL. t~NL?Q )' (_AP-t)UN S: L L.C,
*Legally Responsible Person: Mit,P LL. Q. RoQwSoiN.J
Title of Legally Responsible Person: 0112.,E.L10K TRANSrY115510 r1
*Signature: _ ---;41 Date: 3) la/&Da4-
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
►71o1'P (.fl2-011.3 Lt— ►\ev,N1AAE - r 506Z-l'91tO4•1 E�JG�nt
*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.