NCC190869_Notice of Termination_20200618

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/18/2020 2:26:00 PM (NOT Submittal)
Approve by Georgoulias, Bethany 6/18/2020 2:33:19 PM (NOT Request Review- NCC190869)
p Close-out documents (final inspection report) was uploaded with a previous attempted NOT submittal
and will be included with the final permit record.
• The task was assigned to Georgoulias, Bethany. The due date is: June 23, 2020 5:00 PM
6/18/2020 2:26 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190869
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
Information associated with this permit
Project Name
NGIC Parking Lot
Address
Hanes Mill Road, Winston-Salem, NC
County
Forsyth
Latitude
36.1788
Longitude
-80.2819
Permittee Listed
National General Insurance Company
Legally Responsible
David Wolf
Individual
NC Reference No.
NCG01-2019-0869
E&SC Plan ID
EN1900055
Original NOI
13162
Tracking No.
Date COC Issued
7/8/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of submittal.
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 * O Mistake or Invalid Coverage
r Other
Addional We information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 6/12/2020
Inspection Approval

Project Close-out certification form.pdf
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
130.91 KB
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; 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 deice or method required to be operated or maintained under this Article or rules ofthe
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
Type Name* David Wolf
Title * Vice President
Organization* National General Insurance Company
Date * 06/18/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 212 430 0011
NOT Certification certification form.pdf 130.91 KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]