NCC203561_NOT Signed Certification_20231010

•it cti ns:
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 FOR UNTIL YOUR NOT REQUEST HAS BEEN REVIEED AND APPROVED.
THE FOR YOU MAIL MUST BE COCOMPLETEDITH A ORIGI AL SIGNATURE(NOT DIGITAL)140 CFR 122.22)
General Permit Certificate of Coverage (COC) No.: NCC203561
Name of Project: Victory Church PH-II
Per NC General Statute 143-215.68(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.
Legally Responsible Organizational Entity(must match eNOT): Laneway LLC
*Legally Responsible Person (must match eNOT): David Lane
*Title of Legally Responsible Person: Managing Member
Print Name&Title of Signed if Authorized Individual Differs from Legally Responsible Person:
i
I
*Signature: Date:
* 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 8, Item(6)of the NCG010000 permit.