NCC200705_Notice of Termination_20200922

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/22/2020 2:38:34 PM (NOT Submittal)
Approve by Georgoulias, Bethany 9/22/2020 3:01:48 PM (NOT Request Review- NCC200705)
• The task was assigned to Georgoulias, Bethany. The due date is: September 25, 2020 5:00 PM
9/22/2020 2:38 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200705
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
2020 Pole Replacement
Address
multiple Ridgecrest Rd. (start) - W. Battleboro Ave. (end), multiple -
Halifax, NC
County
Halifax
Latitude
36.3304
Longitude
-77.6742
Permittee Listed
Dominion Energy North Carolina
Legally Responsible
Mark Allen
Individual
NC Reference No.
NCG01-2020-0705
E&SC Plan ID
HALIF-2020-010
Original NOI
22205
Tracking No.
Date COC Issued
2/24/2020
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submttal.
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 *
r Mistake or Invalid Coverage
r Other
Add Tonal IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcunentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:

Final Close-out 9/17/2020
Inspection Approval
Project Close-out HALIF-2020-010.pdf
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
20.19KB
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 Artide; 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
�rW,?/, e ' h�'e
Type Name* Donald Hoover
Title * Manager, Electric Transmission and Substation Construction
Organization* Dominion Energy
Date * 09/22/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 8042403342
NOT Certification NCC200705 NOT Certification Form.pdf 103.76KB
Form Mist be RY Fbrrrat
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 Notificaiton Errails
Email [e-mail]