NCC232757_NOT Signed Certification_20230914

N.CGOI. Noce If Ter Ma oon Wan CCerthI ation Form
Print this form, corn lete, scan and upload to the electronic NOT(Rescision) form.
Then, mail the on final 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 HOT MAIL THIS FORM Ur TOL YtCURA NOT REQUEST HAS BEEN REVIEWED A\ID APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) 4O CFR 1.22.22]
General Permit Certificate of C verage (COC) No.: NCC232757
1
Name of Project: Caliber Colli ion
Per NC General Statute 143-215.6E(i any person who knowingly makes any false statement, representation, or
certification in any application, recor , report,plan, or other document filed or required tq be maintained under this
Article or a rule implementing this Ar "cle. . . shall be guilty of a Class 2 misdemeanor whidh may include a fine not
to exceed ten thousand dollars ($10,0 0).
Under penalty of law, I certify that:
I, as an authorized representative, he,eby 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. I
Legally Responsible Orgahizational Entity(must match eNOT): Providence Commons, LLC
*Legally Responsible Person (must match eNOT): Stephen Rosenburgh
*Title of Legally Responsible Person: Owner
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
Matt Fridrich Project Manager
*Signature: Date: 1 l ! ?
* 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 NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6)of the NCGOII10000 permit.