NCC200051_NOT Signed Certification_20220323

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, 61 Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC200051
Name of Project: Charlotte Latin Field House and Parking
Per NC General Statute 143-215.6E (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 NPES 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 is true, complete, and accurate.
Legally Responsible Organizational Entity: Charlotte Latin School, Inc.
*Legally Responsible Person: fetcher Gregory
Title of Legally Responsible
*Signature:
Print Name and Title of Signed (only if autho�.
FIAA (� A:CqF
Head & Chief Financial Officer
Date: '�— `I;Z'-
signing differs from kegally Responsible Person):
0
*IMPORTANT NOTE: This form must be 3klned by a responsible corporate officer thbt 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 NCG010000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.