NCC191685_Notice of Termination_20211019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/19/2021 7:43:46 AM (NOT Submittal)
Approve by Morman, Alaina 10/19/2021 1:26:52 PM (NOT Request Review - NCC191685)
• The task was assigned to Morman, Alaina. The due date is: October 22, 2021 5:00 PM
10/19/2021 7:43 AM

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NORTH CAROLINA
EnOmnmertray Quduly
Certificate of NCC191685
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status PAID
2021 Annual Fee Status PAST DUE
May be blank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request until
payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must be
completed first (at the NOD or NOV Review step) to ensure records are routed to the correct folder in the repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Harrisburg Park - Phase 1
Address
191 Sims Parkway, Harrisburg, NC
County
Cabarrus
Latitude
35.3163
Longitude
-80.6598
Permittee Listed
Town of Harrisburg
Legally Responsible
Daniel Stines
Individual
NC Reference No.
NCG01-2019-1685
E&SC Plan ID
CABAR-2020-010
Original NOI Tracking
15494
No.
Date COC Issued
9/4/2019
Prior Rescission Date
Date populates only if COC was already rescinded at time of submittal.
Reason for Rescission/Termination Request:
Reason for Project Closed -Out
Termination of Sale (Another Owner/Operator obtained a new COC)
Coverage* Mistake or Invalid Coverage
Other
Additional More information about the basis of this request, if needed.
Explanation Project is complete

Supporting Upload Supporting Documentation if applicable.
Documentation Must be PDF format
Project Close-out Information:
Final Close-out 10/8/2021
Inspection Approval
Project Close-out Harrisburg Park - Closeout Inspection Letter.pdf
Approval Must be PDF format
Documentation
North Carolina General Statute 143-215.613 (1) provides that:
54.2KB
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document
filed 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 device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature 4W�
Type Name* Mallory Hodgson, P.E.
Title* Project Manager
Organization * Town of Harrisburg
Date * 10/19/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7042068779
NOT Certification Harrisburg Park - NCG01 NOT Certification Form.pdf 2.03MB
Form Must be PDF Format
Is this CDC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emails
(Optional) [e-mail]
Original Permittee CC'd on Notification Emails
Email [e-mail]

Original Site Contact cc'd on Notificaiton Ennails
Email [e-mail]