NCG030517_Representative Outfall Status Renewal (Certification)_20211027

FOR AGENCY USE ONLY
NC
ARO FRO MRO RRO WARD WIRO WSRO
Division of Energy, Mineral, and Land Resources Land Quality Section
Representative Outfall Status (ROS) Renewal Certification Form
Please complete this form if you want to maintain current ROS designations.
Directions: Print or type all entries on this certification form. Attach this form and a copy of the original ROS
approval documentation to the Stormwater Upload Form.
North Carolina General Statute 143-215.6E (i) provides that: 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 implefrienting this Article ... shallbeguilty 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, request renewal of the ROS designations currently granted to the subject
facility.
W No site or activity modifications that impact the characteristics of stormwater discharges from the
representative outfalls have occurred at the 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.
Facility Name: Mickey Truck Bodies, Inc. - High Point
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Permit Number: NCG030517
Printed Name of Person Signing: Matt Sink
Title: CEOF l
(Signature of Permittee) (Date Signed)
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NORTH CAROLINA ,
Department of Environmental Quality