NCC190106_NOT Signed Certification_20210831

NCG1 Notice ®f Termination NO I ) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Trees, snail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6'h Floor
1612 Mail Service Center
NC 27699-1612
DC WCT W]A01L TPA B FORM UNTIL VOUR NOT REQUEST HAS BEEEM REViEtWEED AND APPROVED.
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General Permit Certificate & Cooperage (COC) Mo.: NCC190106
Name of Project: HF LEE ASH EENEFICIATI®N
Per NC General Statute 143-215.6B (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: Duke Energy Progress, LLC
*Legally Responsible Person: John _R._Smith _
Title of Legally Responsible
*Signature:
8/3,2oz1
Print Name and Title of Signed (only if authorized individual signing di'fers from Legally Responsible Person):
* IMPORTANTNOTE. This form must be signed by a respons;bfe corporate o)S or - nccL c�,nns or aperates the
construction activity, such as a president, secretary, treasurer, or vice president, or c; 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 fVC6010000 Permit.