NCC192591_Notice of Termination_20201211

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/11/2020 5:12:02 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/14/2020 8:23:53 AM (NOT Request Review- NCC192591)
• The task was assigned to Georgoulias, Bethany. The due date is: December 16, 2020 5:00 PM
12/11 /2020 5:12 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC192591
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status
N/A
Information associated
with this permit:
Project Name
6400 Weant Rd
Address
6400 Weant Rd, Archdale, NC
County
Randolph
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Michael David Byrd
Legally Responsible
Michael Byrd
Individual
NC Reference No.
NCG01-2019-2591
E&SC Plan ID
COA-2020-013
Original NOI
17926
Tracking No.
Date COC Issued
10/31/2019
Prior Rescission
Date populates only if OOC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 12/11/2020
Inspection Approval
Project Close-out Archdale cancel not.pdf
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
305.01 KB
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowinglyrenders
inaccurate anyrecording 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 notto exceed ten thousand
dollars ($10,000).
rJ 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
Type Name* Michael Byrd
Title * owner
Organization* owner
Date * 12/11 /2020
Email for [e-mail]
Confirmation *
Contact Telephone* 336-442-7669
NOT Certification NOT Termination.pdf
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
372.8KB