NCC202719_NOT Signed Certification_20210917

4,
Print this form, complete, scan and upload to the electronic �OT (Rescission) form.
Then, mail the original form to the NC DEMLR Stormw�ater Program at:
Division of Energy, Mineral & Land Resources Stormivater Program
512 N. Salisbury Street, 61" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC202k19
Name of Project:
Per NC General Statute 143-215.6B (i), any person who knowingly makes a y false statement, representation,
or certification in any application, record, report, plan, or other document 'led or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a lass 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
IX 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: Bold Constru
*Legally Responsible Person: Jason Dell
Title of Legally Responsible Person: Presiden
*Signature: -
Print Name ankle of Signed (only if authorized individual signing differs
Date: 09/17/21
Legally Responsible Person):
* IMPORTANT NOTE: This form must be signed by a responsible corporate o icer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice presi ent, or a manager that is
authorized in accordance with Part IV, Section B, Item (6) of the NCGO1000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.