NCC200573_NOT Signed Certification_20210720

NCG01 Notice of Termination (NOT) 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 5tormwater Program at:
Division of Energy, Mineral&Land Resources 5tormwater Program
512 N.Salisbury Street,6"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 122.22]
General Permit Certificate of Coverage (COC) No.: NCC200573
(`,fame of Project: CAPPS to Hendersonville Main 44kV Line Rebuild
Per NC General Statute I43-215.6E(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 5tormwater 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: Duke Energy Carolinas,LLC
*Legally Responsible Person: Randy Velth
Title of Legally Responsible erson: Manager,Permitting
*Signature 1A Date: 7'-20 ' Z!
Print Name and Title of Signed my if authorized individual signing differs from Legally Responsible Person):
" 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 NCG010000 permit_
For more information on signatory requirements,see Part iV,Section B, Item(6)of the NCG010000 permit.