NCC223744_NOT Signed Certification_20240408

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.: N C_L X3 7
Name of Project:Fi3-Farr NI) ► if-6-it•1 (rt4 l?tsis ribu.4 ^ PLC "e„n}-- Pr)r s r l7
Per NC General Statute 143-215.68(1), 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. 1'
Legally Responsible Organizational Entity(must match eNOT): Pia ��"- \144 &c.-
*Legally Responsible Person{must match eNOT): [f la ,(1
*Title of Legally Responsible Person: PfnitGk-
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
•
'Signature: Date: i y
* IMPOR ANT 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.