NCC214688_NOT Certification Form_20231002

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Print, : his form , complete, scan and upload to the electronic NOT ( Rescission ) form .
u �eF� � ; mail the original signed form to the NC [A--- MLR Stormwater Program at :
ivision of Energy, Mineral & Land Resources Stormwater Program
512 N . Salisbury Street, 6t" Floor
1612 Mai ! Service Center
Raleigh , NC 27699- 1612
DO NOT MAIL THIS FORM UNTIL YOUR iNOT REQUEST HAS BEIN RFVIEWED AND APPROVELId" .
T H E F O R M YO U 1ii,Al L M U ST B E C O M P LETE D W I T H AN R I G I N k L S I G NATU R E ( -N- O— T D I GITAL) [40 CF R 12 2. 2 2j
General Permit Certificate of Coverage ( COC ) No . : NCC214688
Name of Project : J igar Patel
Per N C Gen era! Sta tu te 14 3-215. 6B (i), an y p erso n wh o kn o win gly m akes a ny fa lse s ta tem e n t, re�rese n tation, o r
certification in any application, record, report, plan, or other documentfiled or required to be maintained under this
A rticle or a rule implem en tin g th is A rticle , . . sh ah be guilty of a Class Z m isdemean or wh ich m ay in clude a fin e n o t
to exceed ten thousand dollars ($10,0 000) .
Under penalty of lava, I certify that :
I , as an authorized representative, hereby request rescission oi coverage under- the NPDES Stormwater Permit for
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the subject facility ., Ll am familiar with the information contained 0s ,rd phis request, end to the best of my knowledge
:k,. ss �i belief, such information is trUe, complete , &,!, nd accurate .
Legally Responsible 0r•
gan � zational Entity ( must match eNOT ) : Jigar Patel
* Legally Responsible Person ( must match eNOTI. , Jigar Patel
* 'title of Legally Responsible Person : Owner
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Print Name & Title of Signed if Authorized individual Differs from Legally Responsible Verson :
Gary Rhodes , Manager , RHOD S BUILDERS
* Signatu e : _ Date : 16S EP23
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* IMPORTANT NOTE,jp ThM
is 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 manaerg that is authorized in
accordance with Pori IV, Section 8, Item (5) of the NCGO10000 permit.
For more information on signatory requirements, see Part IV, Section B, Item (6) of the NCGO10000 permit.
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