NCC201303_NOT Signed Certification_20230503

NC{GOi Notice of Termination (NOT) Certification Form
Directions:
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the arigirral signed farm to the NC GEMtR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, fill, 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) 14&CFR 122.221
General Permit Certificate of Coverage (COC) No.: NCC201303
Name of Project: Robeson LNG_ Facility - Phase 2
Per NC General Statute 243-215.58 (r), any person who knowingly makes any false statement, representation, or
certification in anyappfrcation, recant report, plan, or other document filed or required to be maintained under
this Articlle or a rule implementing this Article... shall be guilty of a Class 2 misdemeanw which may include o f ine
not to exceed ten thousand dollars (SJQ DDD).
Under penalty of law, I certify that:
1, 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: Piedmont Natural Gas Company, Inc.
'Legally Responsible Person: Bradley Patterstm
`Title of Legally Responsible Person: Delegate
'Signature: Date: d 2 3
'Print Name and Title of Sign (only if authorized individual signing differs turn Legally lfespa►tsibk Perscinj:
' IARPOATAKr AI0TE: This farm must be signed by a responsible corporate offKw that awns or operates the
Construction activity, such as a president, secretary, treasurer, or vice president, or a manager that is authorized in
accordance with Part W, Section 9, hem (6j of the htC60I00W permit.
For more rnforrnation on signatory requirements, see Pert IV, Section H, Item (6) of the NCG0200W permit.