NCC191189_Notice of Termination_20201113

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/13/2020 10:38:11 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/16/2020 7:19:52 AM (NOT Request Review- NCC191189)
• The task was assigned to Georgoulias, Bethany. The due date is: November 18, 2020 5:00 PM
11/13/2020 10:38 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191189
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
Information associated with this permit
Project Name
Ocean Isle Beach Town Park
Address
11 E. Second Street, Ocean Isle Beach, NC
County
Brunswick
Latitude
33.8888
Longitude
-78.4368
Permittee Listed
Town of Ocean Isle Beach
Legally Responsible
Daisy Ivey
Individual
NC Reference No.
NCG01-2019-1189
E&SC Plan ID
BRUNS-2019-081
Original NOI
14274
Tracking No.
Date COC Issued
7/31/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * O Mistake or Invalid Coverage
r Other
Add ional
We information about the basis of this request, if needed.
Explanation
Duplicate COC issued. See COC
NCC191489
Per TPC with Suzanne McCoy, complete
eNOT for this COC. Construction Complete
in June 2020.
Supporting
upload Supporting Docurrentation if applicable.
Documentation
Mist beFDFforrrat

Project Close-out Information:
Final Close-out 6/4/2020
Inspection Approval
Project Close-out 20-0604_lnspection Report Bruns-2019-081.pdf 158.69KB
Approval Mast be FDFforrrat
Documentation
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).
rJ 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
� ?11V
Type Name* Daisy Ivey
Title * Town Administrator
Organization * Town of Ocean Isle Beach
Date * 11 /13/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 910-579-2166
NOT Certification 20-1112 eNOT NCC191189 Certification Form.pdf 377.43KB
Form Mast be FDF Forrrst
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 Kbtificaiton Bmils
Email [e-mail]