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HomeMy WebLinkAboutNCC201702_NOT Signed Certification_20231006 of c: 5 r c ti li 9 i s u Directions: tions: 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 a YOU MARL MUST BE COMPLETED WITH AN ORIGINAL SIGNATURE(NOT DIGITAL) [40 CFR 1?2e1.2:1 General Permit Certificate of Coverage (COC) No.: NCC201702 Name of Project: Lot 13 and 14 Pines at Crescent Ridge Per NC General Statute 143-215.6B(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(must match eNOT): Pakt Construction 'Legally Responsible Person (must match eNOT); Norman Dillard *Title of Legally Responsible Person: Owner Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person: *Signature: Date: JO '6 * 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.