HomeMy WebLinkAboutNCC231175_NOT Signed Certification_20240430 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 122.22]
General Permit Certificate of Coverage (COC) No.: NCC231175
Name of Project: SW-40 S. Alston Ave Sidewalk
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): City of Durham
*Legally Responsible Person (must match eNOT): Tasha Johnson
*Title of Legally Responsible Person: Assistant Director, Public Works
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: 011/2-47 ay-
* IMPORTAN NOTE: This form must signed by a res i le corporate officer that owns or operates the
construction a ivity, such as a preside t,secretary, treasurer, Qr, vice president, or a manager that is authorized in
accordance with Part IV, Section 8, Item the NCGO1D permit.
For more information on signatory requirements,see Part IV,Section 8, Item(6) of the NCG010000 permit.