NCC201095_Notice of Termination_20200625

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/25/2020 11:25:51 AM (NOT Submittal)
Approve by Georgoulias, Bethany 6/25/2020 11:45:31 AM (NOT Request Review- NCC201095)
• The task was assigned to Georgoulias, Bethany. The due date is: June 30, 2020 5:00 PM
6/25/2020 11:25 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201095
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
UNCSA Bailey St Apartments Demolition
Address
1533 S Main Street, Winston-Salem, NC
County
Forsyth
Latitude
36.0770
Longitude
-80.2390
Permittee Listed
University of North Carolina School of the Arts
Legally Responsible
William Martin
Individual
NC Reference No.
NCG01-2020-1095
E&SC Plan ID
FORSY-2020-020
Original NOI
23242
Tracking No.
Date COC Issued
3/20/2020
Prior Rescission
Date populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * O Mistake or Invalid Coverage
r Other
Add ional We information about the basis of this request, if needed.
Explanation Demolition activities have been completed
and construction activities on -site fall under
coverage of FORSY-2020-034
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:

Final Close-out 6/25/2020
Inspection Approval
Project Close-out 06-25-2020 Closure Inspection Report (FORSY-
Approval 34.34KB
2020-020).pdf
Documentation
Mist be PMforrrat
North Carolina General Statute 143-215.613 (i) 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 device or method required to be operated or maintained under this Article or rules of the
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
Wllrrrm' 6;t rrtrzra
Type Name* William Steve Martin
Title * Associate Vice Chancellor - Facilities
Organization * University of North Carolina School of the Arts
Date * 06/25/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 336-770-3322
NOT Certification NC DML NOT - Signed.pdf
Form Mist be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCdon%tificationErrails
Email [e-mail]
Original Site Contact CCd on %tificaiton Errails
Email [e-mail]
581.63KB