NCC190823_Notice of Termination_20200805

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/5/2020 9:02:27 AM (NOT Submittal)
Approve by Georgoulias, Bethany 8/5/2020 10:39:24 AM (NOT Request Review- NCC190823)
• The task was assigned to Georgoulias, Bethany. The due date is: August 10, 2020 5:00 PM
8/5/2020 9:02 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190823
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Verizon Wireless HWY 218 Cell Site
Address
5853 NC 218, Peachland, NC
County
Anson
Latitude
35.0601
Longitude
-80.2767
Permittee Listed
Southern Towers, LP
Legally Responsible
David Hodder
Individual
NC Reference No.
NCG01-2019-0823
E&SC Plan ID
ANSON-2019-007
Original NOI
12999
Tracking No.
Date COC Issued
7/2/2019
Prior Rescission
Date populates only if OOCwas already rescinded at tirre of subaittal.
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 Mxe 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 7/31/2020
Inspection Approval

Project Close-out NC-014_Hwy 218_Construction Stormwater 56.95KB
Approval Inspection Report_08-03-20.pdf
Documentation
Mast be FL7Fforrrat
North Carolina General Statute 143-215.66 (1) 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 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 Hodder
Title * Director of Site Development
Organization* Southern Towers, LP
Date * 08/05/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 423-531-6300
NOT Certification NC-014_Hwy 218_Notice of Termination
Form 50.91 KB
Certificate _08-03-20. pdf
Wst be PM 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 B mils
Email [e-mail]