NCC190911_Notice of Termination_20210802

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/2/2021 4:50:17 PM (NOT Submittal)
Approve by Morman, Alaina 8/5/2021 3:19:06 PM (NOT Request Review- NCC190911)
• The task was assigned to Morman, Alaina. The due date is: August 5, 2021 5:00 PM
8/2/2021 4:50 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190911
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
Dermatology Clininc of the Carolinas
Address
Corporate Circle, Salisbury, NC
County
Rowan
Latitude
35.6433
Longitude
-80.4918
Permittee Listed
Carrol Fisher Construction Company
Legally Responsible
Luke Fisher
Individual
NC Reference No.
NCG01-2019-0911
E&SC Plan ID
Dermatology Group of the Carolinas
Original NOI
13291
Tracking No.
Date COC Issued
7/11/2019
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Cate populates only if COCwas already rescinded at time of submittal.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 12/21/2020
Inspection Approval
Project Close-out Sp102p10320122210380.pdf 394.46KB
Approval Mast be FDFforrrat
Documentation
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 under this 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 of the
Commission implementing this Artcle 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* Luke Fisher
Title * President
Organization* Carrol Fisher Construction
Date * 08/02/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704-361-4949
NOT Certification SharpScanner_20210802_155737.pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCd on Wtification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
386.7KB