NCG080607_Representative Outfall Status Renewal (Certification)_20210917

FOR AGENCY USE ONLY
NC
ARO FRO MRO RRO WARO 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 143-215.6B (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 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, request renewal of the ROS designations currently granted to the subject
facility.
❑✓ 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: NC Air Guard
Permit Number: NCG080607
Printed Name of Person Signing: Sam Ingram
Title: Environmental Manager
INGRAM.SAMUEL.COVI Digits Aby
I NGRAM.S.SAMIJ U ELCOVINGTONJ R.105
NGTON.JR.1053824958 3824958
Date: 2021.09.17 13:25:32-04'00'
09/17/2021
(Signature of Permittee) (Date Signed)
NORTH CAROLINA
Department of Environmental Quality