NCC193134_Notice of Termination_20201211

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/11/2020 1:36:10 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/14/2020 8:26:10 AM (NOT Request Review- NCC193134)
p NOT Certification form uploaded was digitally signed, but mailed in copy should have original
signature.
• The task was assigned to Georgoulias, Bethany. The due date is: December 16, 2020 5:00 PM
12/11/2020 1:36 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC193134
Coverage (COC) Enter the Certificate of Coverage Nimber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status N/A
Information associated with this permit
Project Name
Red Barn Mitigation Bank
Address
Timeless Trail, Mount Airy, NC
County
Surry
Latitude
36.4918
Longitude
-80.6392
Permittee Listed
Ecosystem Planning and Restoration
Legally Responsible
Kevin Tweedy
Individual
NC Reference No.
NCG01-2019-3134
E&SC Plan ID
SURRY-2020-015
Original NOI
19228
Tracking No.
Date COC Issued
12/11/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 *
O 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 Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 8/19/2020
Inspection Approval
Project Close-out 08-19-2020 Closure Inspection Report (SURRY-
Approval 244.33KB
2020-015).pdf
Documentation
Mast be Ft7Fforrrat
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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to 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* Kevin Tweedy
Title * Vice President
Organization* Ecosystem Planning and Restoration, PLLC
Date * 12/11 /2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-999-0262
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form 280.32KB
DEMLR-SW.pdf
Mast be R F Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Erails
CCd on Notification Bmils
[e-mail]
Original Site Contact OCd on Notificaiton Errails
Email [e-mail]