NCG020628_Dormant Status Recertification_20240122

FOR AGENCY USE ONLY
NC
ARO FRO MRO RRO WARO WIRO WSRO
Division of Energy, Mineral, and Land Resources Land Quality Section
NCG020000
Dormant Status Annual Certification Form
Please complete this form if you want to maintain a facility's current dormant status designation.
Directions:
• Print or type all entries on this certification form.
• Attach this form to the Stormwater Upload Form by selecting"Dormant Status Recertification"from the
dropdown menu.
• Once you receive the email stating the upload was received, mail this certification form to the appropriate
DEQ Regional Office.
North Carolina General Statute 143-215.6B (i) provides that: 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:
II I, as the legally responsible person or authorized representative, request renewal of the dormant status
designation currently granted to the subject facility.
ri The subject facility is still temporarily inactive and all portions of the site where clearing, grading, and/or
excavation activities have occurred are stabilized with permanent vegetation.
ET I will notify the Division in writing within thirty(30) days prior to reactivating and/or commencing mining
activity at 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.
Facility Name: �a1g7f IOt` !j5, ( , L-G� ► "1 e
.
Permit Number: 9 - c2s
Date of Dormant Status Approval: a/22//'j
Printed Name of Person Signing: 00e S,n, <—,
Title: 67/V/
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(Signature) / (Date Signed)
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