NCC190983_Notice of Termination_20191127

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/27/2019 2:20:18 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/4/2019 11:29:37 AM (NOT Request Review- NCC190983)
• Georgoulias, Bethany reassigned the task to Georgoulias, Bethany 12/3/2019 7:41 AM
• The task was assigned to Clark, Paul by round robin distribution 11/27/2019 2:20 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: December 2, 2019 5:00
PM 11/27/2019 2:20 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190983
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
Information associated
with this permit:
Project Name
RIVER OAKS COMMUNITY CHURCH
PARKING ADDITION
Address
1855 Lewisville-Clemmons Road, Clemmons, NC
County
Forsyth
Latitude
36.0595
Longitude
-80.3878
Permittee Listed
River Oaks Comm Church Inc
Legally Responsible
David Beaty
Individual
NC Reference No.
NCG01-2019-0983
E&SC Plan ID
EN1900095
Original NOI
13485
Tracking No.
Date COC Issued
7/17/2019
Prior Rescission
This field will populate only if CCChas already been rescinded.
Date
Reason for Rescission/Termination Request:
Reason for
F Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Add Tonal IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcunentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:

Final Close-out 11/15/2019
Inspection Approval
Project Close-out COWS FINAL EROSION REPORT FOR ROCC 11-
Approval 96.95KB
15-19.pdf
Documentation
Mist be RYforrrat
North Carolina General Statute 143-215.613 (i) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Artide or a rule implementing this Artide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 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.
*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 General Permit. For more information on signatory requirements, see Part IV, Section B,
Item (6) of that permit.
Signature
1"Kzv_�
Type Name* David Beaty
Title * Pastor
Organization * River Oaks Community Church Inc
Date * 11/27/2019
Email for [e-mail]
Confirmation *
Contact Telephone* 3367660033
NOT Certification River Oaks Scanner_20191126_154419.pdf 422.17KB
Form Mist be FDF Forrrat