NCC191474_Notice of Termination_20210614

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/14/2021 8:47:36 AM (NOT Submittal)
Approve by Morman, Alaina 6/15/2021 2:43:03 PM (NOT Request Review- NCC191474)
• The task was assigned to Morman, Alaina. The due date is: June 17, 2021 5:00 PM
6/14/2021 8:47 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191474
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
Roxboro Off -Site Borrow Source Charac.- Geotech. Invest. E&SC
Address
Dunnaway Road, Semora, NC
County
Person
Latitude
36.4785
Longitude
-79.0706
Permittee Listed
Duke Energy Progress, LLC
Legally Responsible
Issa Zarzar
Individual
NC Reference No.
NCG01-2019-1474
E&SC Plan ID
PERSO-2019-011
Original NOI
15009
Tracking No.
Date COC Issued
8/21/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 4/29/2021
Inspection Approval
Project Close-out perso-2019-011_rox off site
Approval 48.71 KB
borrow _20210429_INSP RPT.pdf
Documentation
Mist be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording 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 notto 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* Issa Zarzar
Title * General Manager CCP Project Management
Organization* Duke Energy Progress LLC
Date * 06/14/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9195467574
NOT Certification NOTs - Signed - Zarzar - Mayo Roxboro 3.pdf
Form Mast be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification BTails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact OCd on Notificaiton BTails
Email [e-mail]
885.33KB