NCC221617_NOT Signed Certification_20240416

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�22Icvi`7
•
Name of Project: MIS-t helf H( C1100I 'Trw'fi (, T Yb
Per NC General Statute 143-215.6B(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. 'J t,� COy�., �/�
Legally Responsible Organizational Entity(must match eNOT): t 1 ITU'`eiJ W utn4'Vi f1� of
*Legally Responsible Person (must match eNOT): KIWI HO11514o11
*Title of Legally Responsible Person: Executive Director
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
'�anv iZo5oluevvey S 6n i o v VP of- (owofiôvi
Li Servi uc - Ci o c(iwfucec S E.
*Signat r • Date:
* 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.