NCC190641_NOT Signed Certification_20210615

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 RE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No..
Name of Project:
Per NC General Statute 143-215.68 (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 ... sholl 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: _ t 7 0S'� C�y S.1--ca em `e-�
*Legally Responsible Person: R e-x ►a0 S 4—
Title of Legally Responsible Person
*Signatu
ri
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
*IMPORTANTNOTE.• be • by a responsible corporate officer thatowns or operates
construction activity, such ♦ president, iry, treasurer, or r r manager thatauthorized
accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
• � ♦ • • • : � s .� .. ,s r .' • - I till •�