NCC190966_Notice of Termination_20210708

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/8/2021 2:21:01 PM (NOT Submittal)
Approve by Morman, Alaina 7/9/2021 10:41:10 AM (NOT Request Review- NCC190966)
• The task was assigned to Morman, Alaina. The due date is: July 13, 2021 5:00 PM 7/8/2021 2:21 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190966
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
PAID
2021 Annual Fee Status
OPEN
K/hy be blank (if not yet billed).
Information associated
with this permit:
Project Name
Vogler Funeral & Cremation Services At Forsyth Memorial Park
Address
3815 Yadkinville Road, Winston Salem, NC
County
Forsyth
Latitude
36.1530
Longitude
-80.3301
Permittee Listed
SCI North Carolina Funeral Services LLC
Legally Responsible
Michael Decell
Individual
NC Reference No.
NCG01-2019-0966
E&SC Plan ID
EN1900044
Original NOI
13465
Tracking No.
Date COC Issued
7/16/2019
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Cate populates only if COCwas already rescinded at time of submittal.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 5/19/2021
Inspection Approval
Project Close-out sir VOGLER FUNERAL & CREMATIONS 5-19-21
Approval 83.47KB
n.o.t.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 of the
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* Daniel Kleban
Title * Vice President
Organization* SCI North Carolina Funeral Services, LLC
Date * 07/08/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 713-525-5513
NOT Certification SKIM _C55821062810500.pdf
Form Mist be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
69.59KB