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HomeMy WebLinkAboutNCC191987_Notice of Termination_20221025Action 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 If approved, the Certificate of Coverage (COC) will be rescinded.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Original NOI Tracking 16114 No. Date COC Issued 9/26/2019 Prior Rescission Date Date populates only if COC was already rescinded at time of submittal.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 kimberly.young@bcbsnc.com 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 mitch.perry@bcbsnc.com Original Site Contact cc'd on Notificaiton Emails Email julie.schoenagel@bcbsnc.com