NCC204093_NOT Signed Certification_20221117

Print this form, complete, scan and upload tothe electronic NOT (Reodnsinn)form.
Then, mail the original sigmadfonmtothe NCDEMLRGtn/mwaterProgram at:
Division of Energy, Mineral & Land Resources StonnwaterProgram
512N.Salisbury Street, GmFloor
1G12Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate OfCoverage /COC\NO.:
Name n{Project: Aye-r!4 Pond
Per NC General Statute 143-215.6B (i), any person who knowingly makes anyfalse statement, representation, or
certification inany application, record, report, plan, or other documentfiled or required to be maintained under this
Article orurule implementing this Article ... shall be guilty of a Class 2 misdemeanor which may include aftne not
toexceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
Lasanauthorized representative, hereby request rescission ofcoverage under the NPDESStormwaterPermit 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 istrue, complete, and accurate.
Legally Responsible Organizational Entity: I .(j'l t-k0rAeS— NC,LJ_C_
*Legally
Title of Legally Responsible Person-,
*Signature:
Date:
PhntName and Title ofSigned (only ifauthorized individual signing diffemfiromLegally Responsible Peson):
*
IMPORTANT NOTE.- 7hisƒormmust besigned bvoresponsible corporate officer that owns oroperates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that isauthorized /n
accordance with Part IV, Section 4Item (6) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of theWCGO10000 permit