HomeMy WebLinkAboutNCC231757_NOT Signed Certification_20240722 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
General Permit Certificate of Coverage (COC) No.: NCC231757
Name of Project: MORNING GLORY, PHASE ONE - LOT 7
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:
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(must match eNOT): KIMASH HOMES LLC
*Legally Responsible Person(must match eNOT):
JORDAN BROCK
*Title of Legally Responsible Person: OWNER
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
*Signature: Date: 6/6/2023
*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 8, Item(6)of the NCG010000 permit.
For more information on signatory requirements,see Part IV,Section 8, Item(6)of the NCG010000 permit.