NCC201702_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.