NCC202150_NOT Signed Certification_20210503

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
512 N. Salisbury Street, 6" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NGG2
Name of Project
Per NC Generol 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 enalty of law, I certify that:
1, as an authorized representative, hereby request rescission of coverage underthe NPDES
Stormwater Permit forthe subject facility. I am familiar with the information contained in this
request, and to the hest of my knowledge and belief, such information is true, complete, and
accurate.
Legally Responsible Organizational Entity:
* Legally Responsible Person:
Title of Legally Responsible Person:
Signature:
La Diu¢�i
Jrnvss
* 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 B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.