NCC200108_NOT Signed Certification_20220127

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 NOT MAILTHIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REMEWED AND APPROVED,
THE FORM YOU MAiL MMUST RE f-'M&P4
General Permit Certificate of Coverage (COC) No.:
Name of Project:
Per NC General Statute 143-215.6B (1), any person who knowingly makes any false statement, representation, or
certification in any application, record, report plan, or other document filed orrequired to be maintained under thjs
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:
1, as an authorized representative, hereby request rescission of coverage under the :NPDES Stormwater Permit for
the subject facility, 1 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
Title of Legally
*Signature:
M
Date:
Print Nan& and Title of Signed (only if authorized individual signing differs from Legally Respansi.ble Person):
* li4 ORTANT NOTE. This form must be signed by a responsible corporate officer that ovens 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 sign atory requirements, see Part IV, Section B, Item (5) of the NCG010000 permit