NCC203705_NOT Signed Certification_20221117

Print this form, complete, scan and upload tothe electronic NOT (Rescbsion)form.
Then, mail the original signed form tothe NCDEk8LRStormwm1erProgram at:
Division ofEnergy, Mineral & Land Resources 3tonnwaterProgram
512N.Salisbury Street, 6mFloor
1612Mail Service Center
General Permit Certificate OfCoverage /[OC\N0.:
Name of Project:
Per N[General Statute 143-21I68(i),any person who knowingly makes any false statement, representation, or
certification in any application, record, report, plan, or other documentfiled or required tohemaintained under this
Article ororule implementingthisArticle...sho8begu8tynfoC/oss2/nisdemeonorwhichnnoy/ndudeufinenot
toexceed ten thousand dollars ($10,000.
Under penalty of law, I certify that:
Lasonauthorized representative, hereby request rescission ofcoverage under the NPDES StonnwaterPermit 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:
*Legally Responsible Person:
Title ofLegally Responsible Pery:
��^^ ,� ' u
*Signature:
ate:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
*/MPQR7AUV7NO7E. This form must besigned bvoresponsible corporate officer that owns oroperates the
construction activity, such osopresident, secretary, treasurer, orvice president,oromanager that isauthorized /n
accordance with Part IV, Section B, Item (6) of the NCGO10000 permit.
For more information onsignatory requirements, see Part IV, SectiomB, Item (6) ofthe NCG00000permit.