NCC200459_NOT Signed Certification_20221205

Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original signed form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 61h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
DO NOT MAIL THIS FORM UNTIL YOUR NOT REQUEST HAS BEEN REVIEWED AND APPROVED.
THE FORM YOU MAIL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE (NOT DIGITAL) [40 CFR122.221
General Permit Certificate of Coverage (COC) No.:
Name of Project:
'' 1 &
Per NC General Statute 143-215.68 (1), 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, 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, complete, and accurate.
Legally Responsible Organizational Entity: _ -,T-L)401
*Legally Responsible Person: .9 Is 41
Title of Legally Responsible Person:
*Signature:
Print Name and Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
"IMPORTANT , , must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretar)4 treasurer, or vice president, or a manager that is authorized in
accordance with Part IV, Section NCGO10000 permit.