NCC191425_Notice of Termination_20210816

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/16/2021 1:29:31 PM (NOT Submittal)
Approve by Morman, Alaina 8/17/2021 8:58:21 AM (NOT Request Review- NCC191425)
• The task was assigned to Morman, Alaina. The due date is: August 19, 2021 5:00 PM
8/16/2021 1:29 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191425
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
fvby be blank (if not yet billed).
Information associated with this permit:
Project Name
Coscom Water R&R Phase 2
Address
Watson St, Rigger St,Lane St, Jeep St, Transportation St, Logistics St,Goldburg St,
Fort Bragg, NC
County
Cumberland
Latitude
35.1350
Longitude
-78.9610
Permittee Listed
American States Utility Services, Inc.
Legally Responsible
James Cotton
Individual
NC Reference No.
NCG01-2019-1425
E&SC Plan ID
CUMBE-2020-022
Original NOI
14879
Tracking No.
Date COC Issued
8/20/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submttal.
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
Add ional Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload supporting DDcurrentation if applicable.
Documentation NLstbeFOFforrrat

Project Close-out Information:
Final Close-out 8/11/2021
Inspection Approval
Project Close-out CUMBE-2020-022-CO.pdf 33.23KB
Approval Wst be RDFforrrat
Documentation
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 Artide; 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
iHrcp'.���rTerRsrr ��2'rjlrmrsv
Type Name* Timothy Loughman
Title * Utility Manager
Organization * American States Utility Services, Inc.
Date * 08/16/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9104951311
NOT Certification COSCOM PH2 NCG01 NOT CERT_SIGNED.pdf
Form Mist be Ft7F Format
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Bmils
(Optional) [e-mail]
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]
286.78KB