NCC204051_NOT Signed Certification_20240627

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.: C..0 (961406k
Name of Project: VL
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. M n Ite‘o.
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Legally Responsible Organizational Entity(must match eNOT): ` `0. 4w►y V At C.04-Z ot14r-
*Legally Responsible Person (must match eNOT)X �',c.v.. „,`,1.4l,,.acys-
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*Title of Legally Responsible Person: 7t► c_a.
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
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*Signature: Date: 56 "
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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 authorized in
accordance with Part IV,Section 8, Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.
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