NCC220340_NOT Signed Certification_20240411

Noticer ion (NOT) Certificati
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 RE "ED AND APPROVED.
THE FORM YOU MAIL MUS, BE COMPLETED WITH AN ORIGINAL SIGNATURE iHOT DIGITAL}MO CFR 122.221
General Permit Certificate of Coverage (COC) No.: NCC220340
Name of Project: South Asheville Urgent Care Center
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. L
Legally Responsible Organizational Entity(must match eNOT): MN !11isslon I14p/1N, �,�LP
*Legally Responsible Person (must match eNOT): SS llntbi' WIG# CIiIICkiC
*Title of Legally Responsible Person: ChIt7 OprAlinl OICIcGr
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: 3 - 1q- 2024
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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 B, Item (6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.