NCC204138_NOT Signed Certification_20211229

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 ofEnergy, Mineral {\ Land ResuuroeyStormwater Program
512N.Salisbury Street, SmFloor
lG1lMail Service Center
Raleigh, NC27699-1612
NCC2O4138
General Permit Certificate of Coverage (COC) No.:
Name OfProject:
Per NCGeneral Statute 143-215.68(i)any person who knowingly makes onyfalse statement, representation, or
certification in any application, record, report, plan, or other document filed or required to be maintained under this
Article ororule 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:
1, as an authorized representative, hereby request rescission of coverage under the NPDES StonnvvoLerPennbfor
the subject facility. I am familiar with the information contained in this request, and to the best of my knowledge
and belief, such information istrue, complete, and accurate.
Legally Responsible Organizational Entity:
*Legally Responsible Person:
Title of Legally
*Signature:
Sam's Xpress Car Wash
Anthony Warren
Development Manager
Date:
12/2S/2O21
Print Name and-Y'itle of Signed (only if authorized individual signing differsfirom Legally Responsible Person):
*/MPOR7AWNTNOTf. This form must besigned bvo responsiblecorporate officer that owns oroperates the
construction activity, such as a president, secretary, treasurer, or vice president, or manager that is authorized in
accordance with Part IV, SectionB, Item (6) of the NCGO10000permit.
For more information onsignatory requirements, see Part IV, SectionB, Item (6)ofthe N[GO10000pmmit.