NCC191440_Notice of Termination_20201210

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/10/2020 7:32:21 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/11/2020 3:16:38 PM (NOT Request Review- NCC191440)
• The task was assigned to Georgoulias, Bethany. The due date is: December 15, 2020 5:00 PM
12/10/2020 7:32 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC191440
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee
OPEN
Status
Information associated
with this permit:
Project Name
Stanly County EMS
Address
Hilco Street, Albemarle, NC
County
Stanly
Latitude
35.3493
Longitude
-80.1609
Permittee Listed
County of Stanly
Legally Responsible
Andy Lucas
Individual
NC Reference No.
NCG01-2019-1440
E&SC Plan ID
STANL-2020-003
Original NOI
14912
Tracking No.
Date COC Issued
8/22/2019
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Cute populates only if CCCwas already rescinded at tirre of submttal.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 10/23/2020
Inspection Approval
Project Close-out Final Close-out Insepction Approval.pdf 11.91KB
Approval Mast be FDFforrrat
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
rrwjr6zd
Type Name* Andy Lucas
Title * County Manager
Organization* Stanly County
Date * 12/10/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 7049846427
NOT Certification NOT Certification Form.pdf 383.9KB
Form Mast be FDF Forrrat
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 Emils
Email [e-mail]