NCC192124_Notice of Termination_20200713

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/13/2020 12:37:27 PM (NOT Submittal)
Approve by Georgoulias, Bethany 7/20/2020 7:35:51 AM (NOT Request Review- NCC192124)
• The task was assigned to Georgoulias, Bethany. The due date is: July 16, 2020 5:00 PM
7/13/2020 12:37 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192124
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Dunbarton Stream Restoration Project
Address
N Oak Ridge Blvd, Durham, NC
County
Durham
Latitude
36.0000
Longitude
-79.0000
Permittee Listed
Land Mechanic Designs, Inc.
Legally Responsible
Lloyd Glover
Individual
NC Reference No.
NCG01-2019-2124
E&SC Plan ID
DURHA-2019-020
Original NOI
16447
Tracking No.
Date COC Issued
10/2/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 inforrration 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 7/10/2020
Inspection Approval

Project Close-out Dunbarton Sedimentation Inspection Report 7-13-
Approval 93.21 KB
2020.pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowinglyrenders
inaccurate anyrecording or monitoring deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto 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* Lloyd A. Glover
Title * Vice President
Organization* Land Mechanic Designs, Inc.
Date * 07/13/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9196396132
NOT Certification Dunbarton NCG01 Notice of Termination (NOT)
Form Certification Form.pdf
Wst be RY Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]
228.78KB