NCC204318_NOT Signed Certification_20220707

Print this form, complete, scan and upload tothe electronic NOT (Rescission)form.
Then, mail the original signed form tothe NCDEK4LRStormwatorProgram at:
Division nfEnergy, Mineral & Land Resources StonnmaterProgram
` S12N.Salisbury Street, 6eFloor
16l2Mail Service Center
Raleigh, NCJ7G99-1613
so M
General Permit Certificate of Coverage (COC) No.: NCC204318
Name of Project: Wayne Farms VNWTPEffluent Force Main Replacement
Per N[General Statute 243-215.68(I),any person who knowingly makesonyfulse statement, representation, m
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article ororule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include afine not
to exceed ten thousand dollars /$1(l00Cy.
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. I am familiar with the information contained in this request, and to the best of my knowledge
and belief, such information iutrue, complete, and accurate.
Legally Responsible Organizational Entity: Wayne Farms LLC
*Legally Responsible Person:
Kevin McDaniel
Title of Legally R94onsible Person: Chief Operati
*Signature:
Print Name and Title of Signed (only if authorized individual signing differsfrom Legally Responsible :
*IMPORTANTNOTE.7his form must be signed by responsible corporate officer that owns or operates the
construction activity, such oxopresident, secretary, treasurer, orvice president, oromanager that bauthorized /n
accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO1Q000permit.