NCC213648_NOT Signed Certification_20220822

NCG01 Notice of Termination (NOT) Certification Form
Directions,0
Print this form, compete, scan and «I)Io��cf to the electronic NET (Rescission) Form.
Then' mail the original signed form to the NC DEMLR Stormwater ProFr.�t:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61" Floor
1612 Mai! Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED..
SHE FORM YOU MAIL MUST BE COMPLETED W111-1 AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR 122.,22]
General Permit Certificate of Coverage (COC) No.: NCC213648
Name of Project: STR 295 Peach Valley,Cliffside STR 79
Per NC General Statute 143.215.68 (i), any person who knowingly makes any false sratemenrl representation, or
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
Article or ❑ rule implementing this Article. , , shall be gudty of a Class 2 misdemeanor which may include a fine not
to exceed ten thousand dollars ($1 OF 000)4
Under penalty of law., I certify that:
I, 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 is true, compete, and accurate.
Legally Responsible Organizational Entity:
Duke Ener
*Legally Responsible Person: Randy Veltri
Title of Legally
*Signature:
spansible Person:
Carolinas, LLC
Di -rector Transmission Permiff-in
Date: 8/11 L L
Senior Transm'i'ssion Permitting Manager
Print Name and Title af Signed (only if authorized in dividual sign in g differs fro m Legally Responsible Perso n):
IMPO R TA N T NO TE.- Th is fo rm must be signed by cr responsibly corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, ar a manager that is Authorized in
accordance with Part IV, Section B, Item (6) of the NCGO1 0000 permit.
For more information on signatory requirements, see Park IV
,, Section B., Item (6) of the NCGO1 0000 permit.