NCC191856_Notice of Termination_20201209

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/9/2020 3:34:11 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/9/2020 4:27:16 PM (NOT Request Review- NCC191856)
• The task was assigned to Georgoulias, Bethany. The due date is: December 14, 2020 5:00 PM
12/9/2020 3:34 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC191856
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee
PAID
Status
Information associated
with this permit:
Project Name
PNG - Moore Farm Extension
Address
Waxhaw Indian Trail Road, Indian Trail, NC
County
Union
Latitude
35.0464
Longitude
-80.6840
Permittee Listed
Piedmont Natural Gas Company, Inc.
Legally Responsible
Randy Webb
Individual
NC Reference No.
NCG01-2019-1856
E&SC Plan ID
UNION-2020-022
Original NOI
15813
Tracking No.
Date COC Issued
9/13/2019
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Cute populates only if CCCwas already rescinded at tirre of submttal.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 12/11/2019
Inspection Approval
Project Close-out UNION-2020-022_PNG Moore Farm
Approval 36.84KB
CO_12.11.2019.pdf
Documentation
Mast be FL7Fforrrat
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 Arficle; 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 Arficle 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
�' rr-Wj WWI V
Type Name* Randy Webb
Title * Operations Manager
Organization* Piedmont Natural Gas Company, Inc.
Date * 12/09/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9104197215
NOT Certification NCGO1 Notice of Termination Moore Farm.pdf 60.1 KB
Form Mast be PDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Notification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]