NCC192309_NOT Signed Certification_20201229

Notice ate
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
S12 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: CALDW-2020-002
Name of Project: THERMAL VALLEY, INC. EROSION CONTROL PLAN
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).
Linder penalty of laser, I certify that:
1, 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:
THERMAL VALLEY, INC.
* Legally Responsible Person: WILLIAM CRAIG PEARSON
Title of Legally Responsible17Person:
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Signature:
DENT
te: 12/29/2020
* 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 NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.