NCC192277_NOT Signed Certification_20211018

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, 6' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS (FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE -CORM YOU MAIL MAST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CER 122.22r
General Permit Certificate of Coverage (COC) No.: NCC192277
Name of Project:
Oldfield
Per NC General Statute 143-215.69 (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 he 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:
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:
*Legally Responsible Person: James R. Todd
Title of Legally ReWnsible Person: Presi n
*Signature:
ate: 10118/21
Print Name and TitVe of Signed (only if authorized individual signing differs from Legally Responsible Person):
* 1MPORTANT 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 1V, Section B, Item (6) of the NCG010000 permit.