NCC191552_Notice of Termination_20210809

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 8/9/2021 10:31:36 AM(NOT Submittal)
Approve by Morman,Alaina 8/11/2021 2:39:04 PM(NOT Request Review-NCC191552)
• The task was assigned to Morman,Alaina.The due date is:August 12,2021 5:00 PM
8/9/2021 10:32 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 NCC191552
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
May be blank(if not yet billed).
Information associated with this permit:
Project Name West Albemarle Substation
Address Sub Station Road, Edenton, NC
County Chowan
Latitude 36.0940
Longitude -76.5771
Permittee Listed Albemarle Electric Membership Corporation
Legally Responsible Kevin Heath
Individual
NC Reference No. NCG01-2019-1552
E&SC Plan ID Chowa-2019-001
Original NOI 15210
Tracking No.
Date COC Issued 8/28/2019
Prior Rescission Cate populates only if COC was already rescinded at time of submittal.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 7/23/2021
Inspection Approval
Project Close-out 210722 WEST ALBEMARLE SUBSTATION CHOWA-
Approval 246.28KB
2019-001.pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66(1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article;orwho falsifies,tampers with,or knowingly renders
inaccurate anyrecording or monitoring deice 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 notto 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* Kevin Heath
Title* Manager of Engineering
Organization* Albemarle Electric Membership Corporation
Date* 08/09/2021
Email for [e-mail]
Confirmation
Contact Telephone* 252-426-5735 x2230
NOT Certification 20210809103313096.pdf 1022.64KB
Form Mast be PDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]

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