NCC190864_NOT Signed Certification_20201103

Print this form, complete, scan and upload tothe electronic NOT (Rescission)form.
Then, mail the original form tothe NCDEMLRStormwmterProgram at:
Division of Energy, Mineral & Land Resources Stonnvva1erProgram
513 N. Salisbury Street, 6`n Floor
1612Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate OfCoverage b-O[1No.: NCC190864
Name of Project: Bost Custom Homes - Bay Leaf Farms
Per N[General Statute 243-21S68(i),any person who knowingly makes onyfalsestatement, representation,
or certification in any application, record, report, plan, or other documentfiled or required to be maintained
under this Article ororule implementing this Article ... shall beguilty �o��2 m��mcon���m�
/ndudeohnenot toexceed ten thousand uh0ors/$1(IDDD/. '
Under penalty of law, I certify that:
1, 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: Bost Custom Homes
* Legally Responsible Person: Rex A.Bost
Title ofLegally Responsible Person: President, Owner
Signature:__
*
IMPORTANTNOTE. This form must be signed byoresponsible corporate officer that owns orupem/es the
constructionoctivity,suchosopresident,secoebzg|treosurer,orvicep dt,ormrnanogerUimt/s
authorized in accordance with Part IV, Section B, Item (6)mƒthe NCGB 0000 permit.
For more information mnsignatory requirements, see Part IV, Section £L /&ern (6)ofthe g[GU1DODDpermit.