NCC191096_Notice of Termination_20210726

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/26/2021 3:04:04 PM (NOT Submittal)
Approve by Morman, Alaina 7/27/2021 2:15:18 PM (NOT Request Review- NCC191096)
• The task was assigned to Morman, Alaina. The due date is: July 29, 2021 5:00 PM 7/26/2021 3:04 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191096
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
ivby be blank (if not yet billed).
Information associated with this permit:
Project Name
Davidson County Courthouse Addition
Address
East Center Street, Lexington, NC
County
Davidson
Latitude
35.8250
Longitude
-80.2550
Permittee Listed
Davidson County
Legally Responsible
Zeb Hanner
Individual
NC Reference No.
NCG01-2019-1096
E&SC Plan ID
David-2019-031
Original NOI
13972
Tracking No.
Date COC Issued
7/26/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
r Mistake or Invalid Coverage
r Other
Addional Nbre information about the basis of this request, if needed.
Explanation the real address is 110 West Center St,
Lexington, NC

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 11/9/2020
Inspection Approval
Project Close-out 2020 Courthouse Erosion Control Signoff.pdf
Approval Mast be FDFformat
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
135.44KB
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 device 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 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* Dwayne Childress
Title * Support Services Director
Organization * County of Davidson, NC
Date * 07/26/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 3362422030
NOT Certification NCG01 NOT 2020 Courthouse Project .PDF 157.11 KB
Form Mist be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) [e-mail]
Original Permittee 0Cd on Notification BTails
Email [e-mail]

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