NCC190203_Notice of Termination_20210809

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 8/9/2021 9:29:54 AM(NOT Submittal)
Approve by Morman,Alaina 8/11/2021 2:35:07 PM(NOT Request Review-NCC190203)
• The task was assigned to Morman,Alaina.The due date is:August 12,2021 5:00 PM
8/9/2021 9:30 AM

" RequestNOT • Construction Stormwater
1 i
�a•aThis formto request Notice of • • for •co\erage under •
NORTH CAROLINA General - for • i i• Activities Qr�arrry
Certificate of NCC190203
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status PAID
fvby be blank(if not yet billed).
Information associated with this permit:
Project Name Lentz Shooting Range
Address 2030 Gibson Mill Road, Ellerbe, NC
County Richmond
Latitude 35.0588
Longitude -79.6907
Permittee Listed NC Wildlife Resources Commission
Legally Responsible Steven Bailey
Individual
NC Reference No. NCG01-2019-0203
E&SC Plan ID RICHM-2019-006
Original NOI 10753
Tracking No.
Date COC Issued 5/7/2019
Prior Rescission Cate populates only if COC was already rescinded at tin-e of subrrittal.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 Closeout inspection performed by Mike
Lawyer on 7/12/2021.Closeout letter
provided on 7/13/2021.

Supporting upload Supporting Documentation if applicable.
Documentation Wst be FM format
Project Close-out Information:
Final Close-out 7/13/2021
Inspection Approval
Project Close-out Lentz Shooting Range_RICHM-2019-006_7-12-
Approval 93.76KB
2021.pdf
Documentation
Mast be FDFformat
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 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* Steven P Bailey
Title* Facility Construction Engineer
Organization* NC Wildlife Resources Commission
Date* 08/09/2021
Email for [e-mail]
Confirmation
Contact Telephone* 9197070371
NOT Certification NOT Certification Form-Lentz SR-2021-8-9.pdf 63.48KB
Form Mast be FDF Format
Is this COCAlready Ensure this OOC has not been rescinded since subnittal!
Rescinded?
Additional Email OCd on Notification BTails
(Optional)
Original Permittee CCdonNotificationBTails
Email [e-mail]

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