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HomeMy WebLinkAboutNCC192096_NOT Signed Certification_202110191 * - • i s` • Directions: Print this form, complete, scan and upload to the electronic NOT (Rescission) form. Then, mail the original signed form to the INC DEMLR Stormwater Program at: Division of Energy, Mineral & Land Resources Stormwater Program 512 N. Salisbury Street, 6`h Floor 1612 Mail Service Center Raleigh, NC 27699-1612 DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWEL) AND APPROVED. THE FORM YOU MAiL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) (40 CFR 122.221 General Permit Certificate of Coverage (CCIC) No.: MCCA20"JI(P Name of Project: _�� Per NC General Statute 143-215.6B (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: Pt *Legally Responsible Person: Title of Legally Responsible Person: *Signature: Print Name and Title of Signed (only if ltAG. 4 owl' 0170-10 I •• dividuol signing differs from Legally Responsible Person): * 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 IV, Section B, item (6) of the NCGO10000 permit. For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.