NCC240015_NOT Signed Certification_20241120

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.: /� y o°i
Name of Project: Ynapk C!as@, Gdif cov+^ye. X..vwgro ,,evhe +.0"
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, ,n�
Legally Responsible Organizational Entity(must match eNOT):_�7a 1''ky l i l oc►9ala ke,,4 } S erg ices t.Y t'
*Legally Responsible Person (must match eNOT): L.y4'' PA...A p ky _
*Title of.Legally Responsible Person: Pre S i Ae.,.►.V _
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
cL?vto Marpill
*Signature: _.. Date:
2o2
*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.