NCC200576_Notice of Termination_20200807

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/7/2020 11:15:48 AM (NOT Submittal)
Approve by Georgoulias, Bethany 8/10/2020 9:14:51 AM (NOT Request Review- NCC200576)
• The task was assigned to Georgoulias, Bethany. The due date is: August 12, 2020 5:00 PM
8/7/2020 11:15 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200576
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
7295 Tyner Road
Address
7295 Tyner Road, Walkertown, NC
County
Forsyth
Latitude
36.2042
Longitude
-80.1180
Permittee Listed
?
Legally Responsible
Leroy Everhart
Individual
NC Reference No.
NCG01-2020-0576
E&SC Plan ID
EN2000015
Original NOI
21874
Tracking No.
Date COC Issued
2/18/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 * O Mistake or Invalid Coverage
r Other
Add ional We information about the basis of this request, if needed.
Explanation Construction is completed and ground
stabilized
Supporting upload Supporting Docurrentation if applicable.
Documentation Mist beFDFfornat
Project Close-out Information:

Final Close-out 8/4/2020
Inspection Approval
Project Close-out NCG01-eNOT-Certification-Form-20190508-
Approval 1.29MB
DEMLR-SW.pdf
Documentation
sir EVERHART RESIDENCE 8-4-20 (1).pdf 126.66KB
Certificate of Coverage (2).pdf 40.81 KB
Mist be FDFforrrat
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
Type Name * Leroy W. Everhart
Title * Owner
Organization* Site
Date * 08/07/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 336-978-7327
NOT Certification NCGO1 NOT Certification Signed 8-7-2020.pdf 442.72KB
Form Mist be FDF Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Wificaiton Errails
Email [e-mail]