NCC211367_NOT Signed Certification_20210928

Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEM LR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6th Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
,�ayr�" s...�5`=R��.='i,?"4o- '�, d z i::. 45:"i zpe'' k'�. e..-„4 Q'? ;'i'' BE —EN �i" 4_ d i , 1 �r.i i`�4, .....�. .
7 E F"Y 3flF a S f u O t ` E �.'g r �, V E H AN,`
N O r >a G A ,Sa,.V1A R E'° R .h L.! e ��,",. T1 r( r. 2
General Permit Certificate of Coverage (COC) No.:
NCC211367
Name of Project: Jacksonville - Womack 115kV - Install Switches for JOEMC
Per NC General Statute 143-215.68 (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: Randy Veltri
Title of Legally Responsible Person: Director of Transmission Permitting
*Signature: ''mow "` , Dater.
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
Josh Witherspoon, Senior Transmission Permitting 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 8, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section 8, Item (6) of the NCGO10000 permit.