NCC241887_NOT Closeout Document_20251008 (2)

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.: NCC 1� s
Name of Project: (4 I W Pr1v ( rfiS C Tre,I
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.
Legally Responsible Organizational Entity(must match eNOT): �t�✓USt 4 f Nc�1'1'-t CAAu 4, k W hll 1 7 11
i `v
*Legally Responsible Person(must match eNOT): D9t.,%d t9�5.1trlg'�l
*Title of Legally Responsible Person: A +i4 t- 01 ceciu r JPtCS
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: 91/ /1/1-***--
*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.