NCC192521_Notice of Termination_20210309

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/9/2021 3:54:02 PM (NOT Submittal)
Approve by Morman, Alaina 3/11/2021 2:57:39 PM (NOT Request Review- NCC192521)
• The task was assigned to Morman, Alaina. The due date is: March 12, 2021 5:00 PM
3/9/2021 3:54 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192521
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status PAST DUE
2021 Annual Fee Status Nbybeblank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Reviewstep) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
AT&T Lawndale, NC (A01KON9)
Address
Stage Coach Road, Lawndale, NC
County
Cleveland
Latitude
35.4250
Longitude
-81.4934
Permittee Listed
Bellsouth Telecommunications, LLC
Legally Responsible
Nea Dalton
Individual
NC Reference No.
NCGO1-2019-2521
E&SC Plan ID
CLEVE-2020-005
Original NOI
17620
Tracking No.
Date COC Issued
10/30/2019
Prior Rescission
Cate populates only if CDC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
C Project Closed -Out
Termination of
Q Sale (Another Owner/Operator obtained a new COC)
Coverage *
a Mistake or Invalid Coverage
0 Other

Add ional Nbre infornation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation Mist beFCFforrat
Project Close-out Information:
Final Close-out 1/12/2021
Inspection Approval
Project Close-out CLEVE-2020-005 Final Inspection.pdf 114.69KB
Approval NUst be FCFfornat
Documentation
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 of the
Commission implementing this Artcle 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* Valerie Dorrier
Title * Manager Outside Plant Planning and Engineering Design
Organization* BellSouth Telecommunications, LLC
Date * 03/09/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7047996390
NOT Certification Signed eNOT cert Form.pdf 99.54KB
Form Mist be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]

Original Permittee CCdonKlotificationBmils
Email [e-mail]
Original Site Contact GCd on Nlotificaiton BTails
Email [e-mail]