NCC190113_Notice of Termination_20210412

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/12/2021 10:35:54 AM (NOT Submittal)
Approve by Morman, Alaina 4/13/2021 12:28:56 PM (NOT Request Review- NCC190113)
• The task was assigned to Morman, Alaina. The due date is: April 15, 2021 5:00 PM
4/12/2021 10:36 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190113
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
Nt3y be blank (if not yet billed).
Information associated with this permit:
Project Name
Building 3-7 Demolition - Harvey Point Legacy Bdgs Demolition
Address
2835 Harvey Point Rd, Bethel, NC
County
Perquimans
Latitude
36.1083
Longitude
-76.3556
Permittee Listed
Harvey Point Defense Testing Activity
Legally Responsible
Christopher Houtz
Individual
NC Reference No.
NCG01-2019-0113
E&SC Plan ID
Perqu-2019-007
Original NOI
10447
Tracking No.
Date COC Issued
4/26/2019
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained 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 Documentation if applicable.
Documentation Mist beRYforrrat

Project Close-out Information:
Final Close-out 10/13/2020
Inspection Approval
Project Close-out 2020-10 NCDEQ NCC190113 NCDEQ Sedimentatin
Approval 423.09KB
Inspection Report. pdf
Documentation
Mist 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* Felicia Kraintz
Title * Environmental Safety Program Manager
Organization* Harvey Point Defense Testing Activity
Date * 04/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 2524264360
NOT Certification NCG01-eNOT-Certification-Form-Bldg 3-7
Form Demolition_ NCC190113Signed.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonWificationBails
Email [e-mail]
Original Site Contact CCd on Notificaiton F-nails
Email [e-mail]
765.58KB