NCC232509_NOT Closeout Documents (2)_20250114

NCGO1 Notice r i ti ( IT) Certification Form
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 NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 122.221
General Permit Certificate of Coverage (COC) No.: NCC232509
Name of Project: WILSON MALL
Per NC General Statute 143-215.6E(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 Op the information contained in this request,and to the best of my knowledge
and belief, such informationt'is true, complete,and accurate.
Legally Responsible Organizational Entity(must match eNOT): CITY OF WILSON
*Legally Responsible Person (must match eNOT): RODGER LENTZ
*Title of Legally Responsible Person: ASSISTANT CITY MANAGER
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
C
*Signature: Date: 1/13/2025
* IMPORTANT NOTE: This form must be sig ed 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 NCG010000 permit.