NCC190677_Notice of Termination_20201202

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/2/2020 11:11:09 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/3/2020 7:58:14 AM (NOT Request Review- NCC190677)
• The task was assigned to Georgoulias, Bethany. The due date is: December 7, 2020 5:00 PM
12/2/2020 11:11 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190677
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Rough Horn Swamp (I and II) Restoration Site
Address
CCC Road, Evergreen, NC
County
Columbus
Latitude
34.4478
Longitude
-78.9392
Permittee Listed
KCI Technologies Inc.
Legally Responsible
Timothy Morris
Individual
NC Reference No.
NCG01-2019-0677
E&SC Plan ID
COLUM-2019-011
Original NOI
12568
Tracking No.
Date COC Issued
6/20/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 12/1/2020
Inspection Approval

Project Close-out Inspection Report _Rough Horn Swamp 111
Approval Restoration Site COLUM-2019-011 12-01-2020 248.86KB
Documentation
(003).pdf
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 Artide 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 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
We�t4'.'
Type Name* Timothy Morris
Title * Senior Associate
Organization * KCI Environmental Technologies and Construction Inc.
Date * 12/02/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9197936886
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form 243.54KB
DEMLR-SW.pdf
Mast be FDF Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wtification Bmils
Email [e-mail]
Original Site Contact CCd on Nutificaiton BTails
Email [e-mail]