NCC190304_Notice of Termination_20200904

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/4/2020 4:43:31 PM (NOT Submittal)
Approve by Georgoulias, Bethany 9/8/2020 1:45:25 PM (NOT Request Review- NCC190304)
• The task was assigned to Georgoulias, Bethany. The due date is: September 9, 2020 5:00 PM
9/4/2020 4:43 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190304
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
AT&T Glen Alpine, NC (A01GGSJ)
Address
Paddys Creek Rd at Claras Way to Dobson Knobb Rd, Glen Alpine,
NC
County
Burke
Latitude
35.7747
Longitude
-81.9231
Permittee Listed
Bellsouth Telecommunications, LLC
Legally Responsible
Kevin Hogsed
Individual
NC Reference No.
NCG01-2019-0304
E&SC Plan ID
BURKE-2019-015
Original NOI
11092
Tracking No.
Date COC Issued
5/17/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submttal.
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 inforr ation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcunentation if applicable.
Documentation Mist beFDFfornat
Project Close-out Information:

Final Close-out 8/20/2020
Inspection Approval
Project Close-out BST Inspection Report - NC Dept of Environmental
Approval 65.5KB
Quality.pdf
Documentation
Mast 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 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 device 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 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* Mike Wiggin
Title * Director
Organization* Bellsouth Telecommunications
Date * 09/04/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 336-549-4868
NOT Certification Signed NOT Form 19NC03.pdf 29.1 KB
Form Mast be FDF Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Klotification Bmils
Email [e-mail]
Original Site Contact CCd on %tificaiton Errails
Email [e-mail]