NCC231467_NOT Signed Certification_20240711

.1 otic- r i
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,6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NO
HTI�ORREQUEIT HAS BEEN REVIEWED AND GINAL tGNATlY1RE(NOT D IgAL)( VCFR 12 ,22
ED.
THE FORMYOU MAIL MUST BE COMPLETED ``llJJ/
General Permit Certificate of Coverage (COC) No.:
NcC2 3I°"Ib7
Name of Project: WALMUZI 112 if — ID EA/VE/2 2 3- t.b i14 9)
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. . .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:
Permit for
I,as an authorized representative, hereby request rescissionin thige under s requ request, to®he best of my Stormwater
knowledge
the subject facility. I am familiar with the information contained
and belief,such information is true,complete, and accurate.
Legally Responsible Organizational Entity(must match�e l�� C�S����S
*Legally Responsible Person (must match eNOT): � I���GT In n � `�� ��
cf
*Title of Legally Responsible Person:
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
Date:�� � �
*Signature:
cer that owns
operates
the
* IMPORTANT NOTE: This form must be signed by a responsible bloecorporate
r vice p pretsiden/t or a manag o that is authorized in
the .
construction activity,such as a president,secretary,NCG010000 permit
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