NCC203603_NOT Signed Certification_20210805

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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,6t" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
' AIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEFly, R.EVIEV177- ' 0 7"
T BE COMPLETED WITH AN ORIGINAL SG,: -
General Permit Certificate of Coverage (COC) No.: NCC203603
Name of Project: Southern Crossroads Ralph Stephens Rd. Sidewalk
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: Southern Crossroads,Inc.
*Legally Responsible Person: H.Brantley Powell
Title of Legally Re onsibi President
*Signature: Date: � \
i
Print Name and Title of Sign d (on 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 e, Item (6)of the NCGO10000 permit.
For more information on signatory requirements,see Part IV,Section B, Item (6)of the NCGO10000 permit.