NCC192212_Notice of Termination_20210803

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/3/2021 1:25:03 PM (NOT Submittal)
Approve by Morman, Alaina 8/5/2021 4:40:04 PM (NOT Request Review- NCC192212)
• The task was assigned to Morman, Alaina. The due date is: August 6, 2021 5:00 PM
8/3/2021 1:25 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC192212
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
Maple Street/Merritt Street Sewer Improvements
Address
NCSR 1669 North South Street, Maple, Merritt, Pippen, Porter, Willow Streets &
Rawley Avenue, Mount Airy, NC
County
Surry
Latitude
36.5044
Longitude
-80.6138
Permittee Listed
City of Mount Airy
Legally Responsible
Mitch Williams
Individual
NC Reference No.
NCG01-2019-2212
E&SC Plan ID
SURRY-2020-011
Original NOI
16774
Tracking No.
Date COC Issued
10/14/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submttal.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a new COC)
Coverage * r Mistake or Invalid Coverage
r Other
Add ional Mxe information about the basis of this request, if needed.
Explanation Construction Completed.
Supporting Upload Supporting Gbcurnentation if applicable.
Documentation K/UstbeFDFformat

Project Close-out Information:
Final Close-out 4/30/2021
Inspection Approval
Project Close-out NCDEQ 04-29-2021 Closure Inspection Report
Approval 239.85KB
(BURRY-2020-011).pdf
Documentation
Wst be FDFforrrat
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* Mitch Williams, P.E.
Title * City Engineer
Organization * City of Mount Airy
Date * 08/03/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-786-3580
NOT Certification NCG01-eNOT-Certification-Form-20210514-
Form DEMLR-SW.pdf
Mast be FDF Format
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee C Cd on Notification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Emils
Email [e-mail]
782.1 KB