NCC201214_NOT Signed Certification_20210512

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Directions:
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, 6111 floor
1612 Mail Service Center
Raleigh, NC 27699-1612
NCC201214
General Permit Certificate of Coverage (COC) No.:
Name of Project: Camberly Lot 67
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 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: Herring Realty LI.0
*Legally Responsible Person:
Title of Legally Responsible Person:
*Signature:
Thomas Brian Herring
Managing Member
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Print Name and Title of Staled (only if authorized individual signing differs from Legally Responsible Person):
Nataleigh Carscaddon- Office Manager
* 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 NC6010000 permit.