NCC192490_Notice of Termination_20210602

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/2/2021 8:42:07 AM (NOT Submittal)
Approve by Morman, Alaina 6/3/2021 1:46:57 PM (NOT Request Review- NCC192490)
• The task was assigned to Morman, Alaina. The due date is: June 7, 2021 5:00 PM 6/2/2021 8:42 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC192490
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
PAID
2021 Annual Fee Status
Nbybeblank (if not yet billed).
Information associated
with this permit:
Project Name
Barclay Road Water Main Replacement
Address
Barclay Road/Weiner Street, Chapel Hill, NC
County
Orange
Latitude
35.9288
Longitude
-79.0602
Permittee Listed
Orange Water and Sewer Authority
Legally Responsible
Ed Kerwin
Individual
NC Reference No.
NCG01-2019-2490
E&SC Plan ID
ORANG-2020-002
Original NOI
17599
Tracking No.
Date COC Issued
10/29/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained 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 Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 4/27/2021
Inspection Approval
Project Close-out Final Inspection Report.pdf 24.34KB
Approval Mist be FDFforrrat
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 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* Todd Taylor
Title * Executive Director
Organization* OWASA
Date * 06/02/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9195374216
NOT Certification signed NOT Barclay.pdf 29.47KB
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Erails
[e-mail]
Original Site Contact CCd on Notificaiton snails
Email [e-mail]