NCC201509_NOT Signed Certification_20211124

Directions:
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, 6"' Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS CIEEN REVIEWED AND APPROVED.
I! II: FORM YOU MAII. MUST BECOMPLETED WITH AN ORIGINAL SIC,NATUIt1= (NOT DIGITAL) [40 CI_R't>2,22)
Goncral Permit: Certificate of Coverage (COC) No.: e_ %'�' 1� .��,.,._._ry �.__
Name of Project:
Per NC General Statute 143-215.6B (i), any person who knowingly mokes 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 o rule irnplemeoting this Article ... shall be guilty of a Class 2 misdemeanor which may include a fine not
to exceed fen thousand dollars ($10,000).
Under penalty of law, I certify that:
I, as an authorized representative, hereby request rescission of coverage Under the NPi FS Stormwater Permit for
UM 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:.
Legally Responsible Person: � ��/ QL�r-:.%��
fitle of I_egaUy Respo ble 1' rsois: '/�� _— _ —
Signature: . Bate: _17 9?�
Print Name and Title of Signed (only if authorized individual signing differs from legally Responsible Person):
1MPORTAIVI'Nt rfF. 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 NCG010000 permit.
For more information on signatory requirements, see Port IV, Section B, Item (6) of the NCG010000 permit.