NCC200166_Notice of Termination_20201020

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/20/2020 4:31:23 PM (NOT Submittal)
Approve by Georgoulias, Bethany 10/21/2020 7:43:31 AM (NOT Request Review- NCC200166)
• The task was assigned to Georgoulias, Bethany. The due date is: October 23, 2020 5:00 PM
10/20/2020 4:31 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200166
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
Information associated
with this permit:
Project Name
Horne Creek Tributaries Mitigation Project
Address
Kiger Rd., Pinnacle, NC
County
Surry
Latitude
36.2852
Longitude
-80.5032
Permittee Listed
Water and Land Solutions
Legally Responsible
Kayne Van Stell
Individual
NC Reference No.
NCG01-2020-0166
E&SC Plan ID
SURRY-2020-007
Original NOI
20394
Tracking No.
Date COC Issued
1/23/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 10/15/2020
Inspection Approval

Project Close-out 10-15-2020 Closure Inspection Report (SURRY-
Approval 246.45KB
2020-007).pdf
Documentation
Mast be FDFforrrat
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
Type Name* Kayne Van Stell
Title * Vice President, Ecosystem Design Services
Organization* Water and Land Solutions
Date * 10/20/2020
Email for [e-mail]
Confirmation *
Contact Telephone* [phone]
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form DEMLR-SW signed.pdf
NUst be Ft7F Fornat
Is this COC Already Ensure this CCChas not been rescinded since submttal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]
112.38KB