NCC190450_Notice of Termination_20210625

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/25/2021 1:27:21 PM (NOT Submittal)
Approve by Morman, Alaina 6/25/2021 3:56:48 PM (NOT Request Review- NCC190450)
• The task was assigned to Morman, Alaina. The due date is: June 30, 2021 5:00 PM
6/25/2021 1:27 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190450
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status PAID
fvby be blank (if not yet billed).
Information associated with this permit:
Project Name Raw Water Transmission Replacement Project- Phase II
Address Wellfield Road (NC SR 1309) & West Main Street Extension (NC SR 1309), City of
Elizabeth City, NC
County Pasquotank
Latitude 36.3087
Longitude-76.2708
Permittee Listed City of Elizabeth City
Legally Responsible Richard Olson
Individual
NC Reference No. NCG01-2019-0450
E&SC Plan ID Pasqu-2019-005
Original NOI 11638
Tracking No.
Date COC Issued 6/3/2019
Prior Rescission Date populates only if CCCwas already rescinded at tirre of submttal.
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
Add ional Nbre inforrration about the basis of this request, if needed.
Explanation Mr. Olson no longer with City, Mr. Dwan Bell
is the City's Public Utilities Director

Supporting Upload Supporting Documentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 6/8/2021
Inspection Approval
Project Close-out Elizabeth City Sed EC Final Inspection RAW WATER
Approval 31.91 KB
E CITY PASQU-2019-005.pdf
Documentation
Mast be PDFformat
North Carolina General Statute 143-215.613 (i) 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 Artide 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 device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 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* Dwan Bell
Title * Public Utilities Director
Organization * City of Elizabeth City
Date * 06/25/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 252 337-6628
NOT Certification EC eNOT for DEQ 6.25.21.pdf 105.11 KB
Form Mast be FDF Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) [e-mail]
Original Permittee OCd on Notification BTails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]