HomeMy WebLinkAboutNCC192210_Notice of Termination_20201209Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/9/2020 1:57:49 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/9/2020 3:01:05 PM (NOT Request Review- NCC192210)
• The task was assigned to Georgoulias, Bethany. The due date is: December 14, 2020 5:00 PM
12/9/2020 1:57 PM
1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC192210
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee
OPEN
Status
Information associated
with this permit:
Project Name
UNION GENERAL HOSPITAL INC, MEDICAL CLINIC
Address
NC HWY 69, HAYESVILLE, NC
County
Clay
Latitude
35.0320
Longitude
-83.8220
Permittee Listed
PENLAND CUSTOM BUILDERS INC
Legally Responsible
ROBERT PENLAND
Individual
NC Reference No.
NCG01-2019-2210
E&SC Plan ID
CLAY 2020-001
Original NOI
16747
Tracking No.
Date COC Issued
10/9/2019
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Cute populates only if CCCwas already rescinded at tirre of submttal.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 12/8/2020
Inspection Approval
Project Close-out Close -Out Inspection Report 12-8-2020.pdf 279.6KB
Approval Must 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 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
0141t a54;11ex�
Type Name* Jared Shook
Title * Project Manager
Organization* Penland Custom Builders, Inc
Date * 12/09/2020
Email for JShook@penlandbuilders.com
Confirmation *
Contact Telephone* 8283421327
NOT Certification NOTcloseout.pdf 852.93KB
Form Mist be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee 0Cd on Notification Brails
Email ROBERT@PENLANDBUILDERS.COM
Original Site Contact CCd on Notificaiton Bmils
Email CHADHOOPER@UNIONGENERAL.ORG