NCC190818_Notice of Termination_20201106

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/6/2020 8:31:58 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/17/2020 9:17:41 AM (NOT Request Review- NCC190818)
* Permittee confirmed construction project was closed out before sale; provided confirmation from town
of Archdale via e-mail (will be added to file).
• The task was assigned to Georgoulias, Bethany. The due date is: November 11, 2020 5:00 PM
11 /6/2020 8:32 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190818
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
102 GRACIE COURT
Address
102 GRACIE COURT, ARCHDALE, NC
County
Guilford
Latitude
35.9222
Longitude
-79.9547
Permittee Listed
BERNICE EARNHARDT
Legally Responsible
BERNICE EARNHARDT
Individual
NC Reference No.
NCG01-2019-0818
E&SC Plan ID
COA-2019-010
Original NOI
13031
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 r Project Closed -Out
Termination of F Sale (Another Owner/Operator will apply for a new COC)
Coverage * r Mistake or Invalid Coverage
r Other
Addional Nbre inforrration about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcurrentation if applicable.
Documentation 102 Gracie Court Deed.pdf 427.27KB
Mast be FOF forrrat
Project Close-out Information:

Final Close-out
Inspection Approval
Project Close-out Mast beFDFforrrat
Approval
Documentation
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 Artide or a rule implementing this Artide; 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 Artide 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* Bernice Earnhardt
Title * Owner
Organization* Bernice Earnhardt
Date * 11/06/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 3362896178
NOT Certification NOT FORM 102 GRACIE COURT.pdf
Form Mast be FDF Format
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCdonWtificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]
326.32KB