NCC201654_NOT Signed Certification_20220207

Print this form, complete, scan and upload tothe electronic NOT (Rescission)form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land ResourcesS1onnvvoter Program
512N. Salisbury Street, 6mFloor
1612Mail Service Center
Raleigh, NCZ7698'1613
General Permit Certificate of Coverage (COC) No.: NCC201654
Name OfProject:
The Barony
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article ororule implementing this Article ... shall beguilty ufoClass 2misdemeanor which may include ofine not
toexceed ten thousand dollars ($10,000).
Lasenauthorized representative, hereby request rescission of coverage under the NPDES Stormwater Permit for
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.
Bost CuslomDomCm
Legally Responsible Organizational Entity:
*Legally Responsible Person: Rex Bost
Title of Legally Responsible Person:
President
*Signature: : 2/7/2022
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Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
*IMPORTANTNOTE: 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,