HomeMy WebLinkAboutNCC191965_Notice of Termination_20201207Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/7/2020 4:30:55 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/8/2020 7:47:26 AM (NOT Request Review- NCC191965)
• The task was assigned to Georgoulias, Bethany. The due date is: December 10, 2020 5:00 PM
12/7/2020 4:30 PM
1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191965
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee OPEN
Status
Information associated with this permit:
Project Name
Southern Pines Warrior Woods Sewer Lift Station
Address
Central Drive Hwy 22, Southern Pines, NC
County
Moore
Latitude
35.2208
Longitude
-79.3914
Permittee Listed
Town of Southern Pines
Legally Responsible
James Michel
Individual
NC Reference No.
NCG01-2019-1965
E&SC Plan ID
MOORE-2020-004
Original NOI
16025
Tracking No.
Date COC Issued
9/20/2019
Prior Rescission
Cute populates only if CCCwas already rescinded at tirre of submttal.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
Addional IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting DDcurrentation if applicable.
Documentation NLstbeFOFformat
Project Close-out Information:
Final Close-out 12/3/2020
Inspection Approval
Project Close-out MOO RE-2020-004-CO.pdf 57.07KB
Approval Wst be Ft7Fforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Pnyperson 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 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
C'Z? rW / r/r_t
Type Name* James Michel
Title * Town Engineer
Organization* Town of Southern Pines
Date * 12/07/2020
Email for jmichel@southernpines.net
Confirmation *
Contact Telephone* 910-692-1983
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form 45.52KB
DEMLR-SW signed.pdf
Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification BTails
Email jmichel@southernpines.net
Original Site Contact CCd on Kbtificaiton Bmils
Email jmichel@southernpines.net