NCC231515_NOT Signed Certification_20240514

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 ICE COMPLETEO WITH A0 proomt.SI?SIGNATURE E 11 OT DIGITAL}Oi1 OR:1
General Permit Certificate of Coverage (COC) No.: N)CC. r 3151S
Name of Project: Six pnc. Cf.
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): SV'Oft'-10"Y\�j
*Legally Responsible Person (must match eNOT): ShU 'l1\Ori
*Title of Legally Responsible Person: EtA (V '^
Print Name &Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: `-f\R 1 L
* IMPO NT NOT • is 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.