NCC200540_NOT Signed Certification_20211102

-tification Form
Directions:
Print this form, complete, scan and upload to the electronic N OT (Rescission) form.
Then, mail the original form to the NC DEMLR Stormwa er Program at:
Division of Energy, Mineral & Land Resources Storm ater Program
512 N. Salisbury Street, 6t" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
Gelieral Permit Certificate of Coverage (COC) No.:
Nailne of Project:
Per NC General Statute 143-215.6B (i), any person who knowingly makes an false statement, representation,
or certification in any application, record, report, plan, or other document fil d or required to be maintained
under this Article or a rule implementing this Article ... shall be guilty of a C ass 2 misdemeanor which may
include a fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
iJ I, as an authorized representative, hereby request rescission of coverage under the NPDES
Stormwater Permit for the subject facility. I am familiar with the ir formation contained in this
request, and to the best of my knowledge and belief, such informa Lion is true, complete, and
accurate.
Leg- Ily Responsible Organizational Entity: BOLD Construction Inc
*Leg- lly Responsible Person: Sheen HosseinDOur
Title of Legally Res*n%le Person: Operations Coordina
*Signature:
ate: I
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANT NOTE: This farm must be signed by a responsible corporate ofj
com truction activity, such as a president, secretary, treasurer, or vice presid
authorized in accordance with Part IV, Section B, Item (6) of the NCGO10000
For more information on signatory requirements, see Part IV, Section B, Iterr
,r that owns or operates the
t, or a manager that is
(6) of the NCG010000 permit.