NCC192293_Notice of Termination_20210728

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/28/2021 11:55:12 AM (NOT Submittal)
Approve by Morman, Alaina 7/29/2021 1:53:54 PM (NOT Request Review- NCC192293)
• The task was assigned to Morman, Alaina. The due date is: August 2, 2021 5:00 PM
7/28/2021 11:55 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192293
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 Forsyth County Clemmons Branch Library
Address 6365 James Street, Clemmons, NC
County Forsyth
Latitude 36.0300
Longitude-80.3780
Permittee Listed Forsyth County
Legally Responsible Damon Sanders -Pratt
Individual
NC Reference No. NCG01-2019-2293
E&SC Plan ID Forsy-2020-010
Original NOI 17015
Tracking No.
Date COC Issued 10/11/2019
Prior Rescission Cate populates only if COCwas already rescinded at tirre of subrrittal.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 7/8/2021
Inspection Approval
Project Close-out 07-08-2021 Closure Inspection Report (FORSY-
Approval 244.88KB
2020-010).pdf
Documentation
Mist be FDFforrrat
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* Damon Sanders -Pratt
Title * Deputy County Manager
Organization* Forsyth County
Date * 07/28/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-703-2008
NOT Certification NCGO1 NOT Cert.pdf 67.04KB
Form Mast be FDF Forrrat
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 Enails
Email [e-mail]