NCC190013_Notice of Termination_20201221

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/21/2020 2:24:10 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/21/2020 2:32:08 PM (NOT Request Review- NCC190013)
• The task was assigned to Georgoulias, Bethany. The due date is: December 24, 2020 5:00 PM
12/21/2020 2:24 PM

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NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190013
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status N/A
Information associated with this permit
Project Name
HYDE PARK BAPTIST CHURCH
Address
301 ROBERTS AVE, LUMBERTON, NC
County
Robeson
Latitude
34.6161
Longitude
-78.9824
Permittee Listed
HYDE PARK BAPTIST CHURCH
Legally Responsible
RANDY HAMMONDS
Individual
NC Reference No.
NCG01-2019-0013
E&SC Plan ID
Robes-2019-019
Original NOI
9890
Tracking No.
Date COC Issued
4/5/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submittal.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 *
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 12/14/2020
Inspection Approval
Project Close-out ROBES-2019-019 Hyde Park Baptist Church Insp
Approval 56.89KB
12-14-2020. rtf. pdf
Documentation
Mast be FDFforrrat
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* Randy Hammonds
Title * Project Manager
Organization * Hyde Park Baptist Church
Date * 12/21 /2020
Email for orrumraiders51 @gmail.com
Confirmation *
Contact Telephone* 910-608-1266
NOT Certification Hyde Park BC_NCN190013 NOT Cert Form.pdf
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email 0Cd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email orrumraiders51 @gmail.com
Original Site Contact OCd on Notificaiton STails
Email [e-mail]
76.64KB