NCC200065_NOT Signed Certification_20220110

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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, 6t" Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOTIVI IL THIS FORM 1e1NT]L. YOUk NOT R QVEST HAS BEEN REVlF_WED AND APPROVED.
'THE F+ RIM YOU MAIL IMUST BE COMPLFTfT) lklfflI € N ORIGINAL `o16NA'rURE (NOT DIGITAL) [40 CFR 1.22.221
General Permit Certificate of Coverage (COC) No
Name of Project: ti ►V66 Ty ,C, Apt*,
N(Y-aOCC(¢S= aOa;k
Per NC General Statute 143-215.6B (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 Storrwater Permit for
the subject facility. I am familiar with than information containers in this rt-..,q ue.st, and i:o the best of my knowledge
and belief, such information is true, complete, and accural.e.
Legally Responsible Organizational Entity: Q)tyerys TyrAte, LL&
*Legally Responsible Person: Du; h)\I R,1 ItS
Title of Legally Responsible Person: MA:rKv� FA-e,—
*Signature:
I — I O-Zo22
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* 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 B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, [tern (6) of the NCGO10000 permit.