NCC200508_Notice of Termination_20200210

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/10/2020 10:46:06 AM (NOT Submittal)
Approve by Garcia, Lauren V 2/10/2020 10:57:46 AM (NOT Request Review- NCC200508)
• The task was assigned to Garcia, Lauren V by round robin distribution 2/10/2020 10:46 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 13, 2020 5:00
PM 2/10/2020 10:46 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200508
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Ward Residence
Address
Deaverview Road, Asheville, NC
County
Buncombe
Latitude
35.5857
Longitude
-82.6469
Permittee Listed
N/A
Legally Responsible
John Ward
Individual
NC Reference No.
NCG01-2020-0508
E&SC Plan ID
ER02019-00062
Original NOI
21529
Tracking No.
Date COC Issued
2/10/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * F Mistake or Invalid Coverage
r Other
Addional Nbre inforrration about the basis of this request, if needed.
Explanation
Supporting upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out
Inspection Approval

Project Close-out Mast beFDFformat
Approval
Documentation
North Carolina General Statute 143-215.66 (1) 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 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 underthis Article; or who falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Article or rules ofthe
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 k47Ww4
Type Name* John T Ward
Title * Owner
Organization* John T Ward
Date * 02/10/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9195220478
NOT Certification NCG01 NOT.pdf 53.82KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?