NCC193293_Notice of Termination_20201102

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/2/2020 5:08:09 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/3/2020 8:09:38 AM (NOT Request Review- NCC193293)
• The task was assigned to Georgoulias, Bethany. The due date is: November 5, 2020 5:00 PM
11/2/2020 5:08 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC193293
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
Information associated
with this permit:
Project Name
Town of Nags
Address
US Hwy 158, Nags Head, NC
County
Dare
Latitude
35.9564
Longitude
-75.6255
Permittee Listed
Town of Nags Head
Legally Responsible
Cliff Ogburn
Individual
NC Reference No.
NCG01-2019-3293
E&SC Plan ID
Dare-2020-002
Original NOI
19834
Tracking No.
Date COC Issued
12/20/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 10/14/2020
Inspection Approval

Project Close-out 2020-14-10 Inspcetion Report PHBA.pdf 145.97KB
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
Type Name* Greg Sparks
Title * Interim Town Manager
Organization* Town of Nags Head
Date * 11 /02/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 2524415508
NOT Certification Certificate of Termination 8A.pdf
Form Mist be FCF Forrrat
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 Bmils
Email [e-mail]
198.08KB