NCC214480_NOT Signed Certification_20240917

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 SIGNATURE1 (NOT DIGITAL) [40 CFR 122.22]
General Permit Certificate of Coverage (COC) No.: I - Z 1 14L1' �O
Name of Project: 5f J C 4w' . C-e/1-1-e7
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. 1
Legally Responsible Organizational Entity(must match eNOT): SL7f� CoU��.Jf
*Legally Responsible Person (must match eNOT): C,I iti \ �.XL6 P� 00
*Title of Legally Responsible Person: 03011,416 kO/1O !_
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: // ` ` l/ Date: ciIi7 �Z(7`
* 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/V,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.