NCC191987_Notice of Termination_20221025

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/25/2022 4:32:50 PM (NOT Submittal)
Approve by Clark, Paul B 10/26/2022 10:43:49 PM (NOT Request Review - NCC191987)
• The task was assigned to Clark, Paul B by round robin distribution 10/25/2022 4:32 PM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: October 28, 2022 5:00
PM 10/25/2022 4:32 PM

Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCGO10000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC191987
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
PAID PAID WAIVED
May be blank if N/A May be blank if N/A May be blank if N/A
Information associated with this permit
Project Name BCBSNC Building 100 Site Improvements
Lots Covered by this This information is especially helpful when more lots were added with Modifications since the original permit
Permit COC (if
issuance.
applicable)
No longer visible on the initial form (data not captured from initial application)
Address
1965/1969 Ivy Creek Blvd, Durham, NC
County
Durham
Latitude
35.9580
Longitude
-78.9630
Permittee Listed
Blue Cross Blue Shield of North Carolina
Legally Responsible
Mitchell Perry
Individual
NC Reference No.
NCG01-2019-1987
E&SC Plan ID
6016-13
Original NOI Tracking
16114
No.
Date COC Issued
9/26/2019
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Date populates only if COC was already rescinded at time of submittal.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 new COC)
Coverage* Mistake or Invalid Coverage
Other
Additional More information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation Must be PDF format
Project Close-out Information:
Erosion Control Plan 6/14/2021
Close-out Date
Erosion Control Plan Letter of Termination BCBS Bldg 100 Site
Close-out Improvements.pdf
Documentation
Must be PDF format
North Carolina General Statute 143-215.6113 (i) provides that:
50.08KB
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
Z rll ryawe
Type Name* Kimberly T. Young
Title* Principal Project Manager, Real Estate & Facility Services
Organization* Blue Cross and Blue Shield of North Carolina
Date* 10/25/2022
Email for [e-mail]
Confirmation *
Contact Telephone* 919-525-4753
NOT Certification NCG01 NOT BCBSNC Executed.pdf 38.88KB
Form Must be PDF Format
Is this COC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emails
(Optional)
Original Permittee CC'd on Notification Emails
Email [e-mail]

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