NCC191420_Notice of Termination_20201116

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/16/2020 6:49:59 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/17/2020 9:29:53 AM (NOT Request Review- NCC191420)
• The task was assigned to Georgoulias, Bethany. The due date is: November 19, 2020 5:00 PM
11/16/2020 6:50 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191420
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
5978 WEANT RD.
Address
5978 WEANT RD, ARCHDALE, NC
County
Randolph
Latitude
35.8930
Longitude
-79.9261
Permittee Listed
BERNICE EARNHARDT
Legally Responsible
BERNICE EARNHARDT
Individual
NC Reference No.
NCG01-2019-1420
E&SC Plan ID
COA-2020-004
Original NOI
14932
Tracking No.
Date COC Issued
8/21/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 11/16/2020
Inspection Approval

Project Close-out Gmail - Fwd_ Close Out for Sites.pdf 110.43KB
Approval Mist be RYforrrat
Documentation
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 knowingly renders
inaccurate anyrecording 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 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* Bernice Earnhardt
Title * Owner
Organization* Bernice Earnhardt
Date * 11 /16/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 3362896178
NOT Certification 5978 Weant Rd NOT.pdf 336.96KB
Form Mist be FCF 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 Notificaiton Errails
Email [e-mail]