NCC200218_NOT Signed Certification_20240531

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.:MC&0 -20W-OZIg /VC C 29021S'
Name of Project: tiI)e�� C,13 4Lin)-1 e ,R.pfri Cf D Den+
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Per NC General Statute 143-215.6E(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. iI1 �1 I, I -/
Legally Responsible Organizational Entity: l/) LXV(vtie fliPCk IeI'[6,{2c &)or f%�� GCII'lL� hoot
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*Legally Responsible Person: T�0 y • ACC Ai
Title of Legally esponsib,Perso : ;{C (_ � D \ P t C k (` !, 11 i2.e
*Signature: • Date: 05:3E.1(Z4
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* 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.