NCC192068_Notice of Termination_20221027

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/27/2022 1:28:11 PM (NOT Submittal)
Approve by Clark, Paul B 10/29/2022 12:49:14 PM (NOT Request Review - NCC192068)
• The task was assigned to Clark, Paul B by round robin distribution 10/27/2022 1:28 PM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: November 1, 2022 5:00
PM 10/27/2022 1:28 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(COC) will be rescinded.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 NCC192068
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
PAID PAID PAID
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 Crossroads Rescue Mission
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
Dekalb St., Shelby, NC
County
Cleveland
Latitude
35.2594
Longitude
-81.5591
Permittee Listed
Crossroads Rescue Mission
Legally Responsible
Rocky Shelton
Individual
NC Reference No.
NCG01-2019-2068
E&SC Plan ID
CLEVE-2019-007
Original NOI Tracking
16325
No.
Date COC Issued
9/27/2019
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Date populates only if COC was already rescinded at time of submittal.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 Plan has expired.
Additional More information about the basis of this request, if needed.
Explanation The site has not started the approved construction activity within the three-year time
frame allowed upon issuance of approval.

Supporting Upload Supporting Documentation if applicable.
Documentation Sedimentation Stormwater Inspecton Report.pdf
Must be PDF format
Project Close-out Information:
Erosion Control Plan
Close-out Date
Erosion Control Plan Must be PDF format
Close-out
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
51.54KB
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
l�,7 l40lb
Type Name* ROCKY SHELTON
Title* EXECUTIVE DIRECTOR
Organization* CROSSROADS RESCUE MISSION
Date * 10/27/2022
Email for [e-mail]
Confirmation*
Contact Telephone* [phone]
NOT Certification SIGNED NOTICE OF TERMINATION.pdf 35.77KB
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) [e-mail]
Original Permittee CC'd on Notification Emails
Email [e-mail]

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