NCC190060_Notice of Termination_20201021

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/21/2020 11:01:04 AM (NOT Submittal)
Approve by Georgoulias, Bethany 10/21/2020 11:43:07 AM (NOT Request Review- NCC190060)
* Permittee omitted NOT Certification form in uploads but provided it via e-mail upon request (will be
added to record).
• The task was assigned to Georgoulias, Bethany. The due date is: October 26, 2020 5:00 PM
10/21/2020 11:01 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190060
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Saints' Delight United Church of Christ
Address
US 401 Hwy S, Louisburg, NC
County
Franklin
Latitude
36.0000
Longitude
-78.0000
Permittee Listed
Michael Leonard Builders LLC
Legally Responsible
Justin Leonard
Individual
NC Reference No.
NCG01-2019-0060
E&SC Plan ID
FRANK-2019-022
Original NOI
10220
Tracking No.
Date COC Issued
4/17/2019
Prior Rescission
Cate populates only if CDCwas already rescinded at tirre of subrrittal.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 1/24/2020
Inspection Approval

Project Close-out Saints Delight CO.pdf
Approval Mist be FDFfornil
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
604.91 KB
Any person who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
document filed 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 under this Article; or who falsifies, tampers with, or knowinglyrenders
inaccurate any recording or monitoring deice 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 may include 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* Justin Leonard
Title * owner/contractor
Organization* Michael Leonard Builders
Date * 10/21 /2020
Email for [e-mail]
Confirmation *
Contact Telephone * [e-mail]
NOT Certification Saints Delight NOT.pdf 1.36MB
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]