NCC216006_NOT Signed Certification_20230111

Directions: -
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,6th°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 CFR 122.221
General Permit Certificate of Coverage (COC) No.: JVC--_2 I boo
Name of Project:
Per NC General Statute 143-215.6B (i), 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:
p y q r 'on of coverage under the, NPDES Storrwater Permit for
I, as an authorized representative, hereby request rescissi
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, acid accurate.
Legally Responsible Organizational Entity:
*Legally Responsible Person: James Bridges and Pinar Bridges
Title of Legally Responsib
*Signature:
n:
Print Name A Title of Signed (only if authorized individual signing differs from Legally Responsible Person):
* IMPORTANT NOTE: This form must be signed by a responsible corporate officer that owns or operates the
construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is authorized in
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 NCGO10000 permit.