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HomeMy WebLinkAboutNCG020628_Dormant Status Recertification_20240122 FOR AGENCY USE ONLY NC ARO FRO MRO RRO WARO WIRO WSRO Division of Energy, Mineral, and Land Resources Land Quality Section NCG020000 Dormant Status Annual Certification Form Please complete this form if you want to maintain a facility's current dormant status designation. Directions: • Print or type all entries on this certification form. • Attach this form to the Stormwater Upload Form by selecting"Dormant Status Recertification"from the dropdown menu. • Once you receive the email stating the upload was received, mail this certification form to the appropriate DEQ Regional Office. North Carolina General Statute 143-215.6B (i) provides that: 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: II I, as the legally responsible person or authorized representative, request renewal of the dormant status designation currently granted to the subject facility. ri The subject facility is still temporarily inactive and all portions of the site where clearing, grading, and/or excavation activities have occurred are stabilized with permanent vegetation. ET I will notify the Division in writing within thirty(30) days prior to reactivating and/or commencing mining activity at 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. Facility Name: �a1g7f IOt` !j5, ( , L-G� ► "1 e . Permit Number: 9 - c2s Date of Dormant Status Approval: a/22//'j Printed Name of Person Signing: 00e S,n, <—, Title: 67/V/ ► 9, q9ac# (Signature) / (Date Signed) 1-1_E Department 01 Emuor etentat Dwtny