NCC200162_Notice of Termination_20201007

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/7/2020 8:54:46 AM (NOT Submittal)
Approve by Georgoulias, Bethany 10/7/2020 10:14:27 AM (NOT Request Review- NCC200162)
• The task was assigned to Georgoulias, Bethany. The due date is: October 12, 2020 5:00 PM
10/7/2020 8:54 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200162
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
UNC West Drive Repaving
Address
West Drive, Chapel Hill, NC 27514, Chapel Hill, NC
County
Orange
Latitude
35.9029
Longitude
-79.0530
Permittee Listed
University of North Carolina at Chapel Hill
Legally Responsible
Jonathan Pruitt
Individual
NC Reference No.
NCG01-2020-0162
E&SC Plan ID
ORANG-2020-010
Original NOI
20564
Tracking No.
Date COC Issued
1/16/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.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
Addional We 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 6/2/2020
Inspection Approval

Project Close-out ORANG-2020-010_20200601_InspRpt.pdf 86.08KB
Approval Mist be RYforrrat
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
�w,, ge ga17e ///
Type Name* George Battle III
Title * Vice Chancellor for Institutional Integrity and Risk Management
Organization* The University of North Carolina at Chapel Hill
Date * 10/07/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-843-0475
NOT Certification NCG01-eNOT-Certification-
Form 373.24KB
Form,_ West_ Drive_Repaving_Project, Signed.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Nbtification Errails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]