NCC213288_NOT Signed Certification_20230808

f Ter ination ( • Certification r
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 CO PLETED 1TH AN ORIGINAL SIGNATURE(NOT DIGITAL)[40 FR 122.22
General Permit Certificate of Coverage (COC) No.: NC
Name of Project: LQ— Jv0.1C1C �'.
Per NC General Statute 143-215.6E(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:
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. 1
Legally Responsible Organizational Entity: /`AQV\�e-Ct\I � k 7I e�.12� LLC
*Legally Responsible Person: 1 aV,a @LA
Title of Legally Responsible P on: Du3ve(^
*Signature: Date:
Print Name and 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 NCG010000 permit.
For more information on signatory requirements,see Part IV,Section B, Item(6)of the NCG010000 permit.