NCC200536_Notice of Termination_20201112

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/12/2020 3:02:48 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/12/2020 3:16:16 PM (NOT Request Review- NCC200536)
• The task was assigned to Georgoulias, Bethany. The due date is: November 17, 2020 5:00 PM
11/12/2020 3:03 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200536
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
RTAMS TLZ Repair - Bluebird
Address
Sneads Ferry Road, Camp Lejeune, NC
County
Onslow
Latitude
34.5550
Longitude
-77.3190
Permittee Listed
United States Marine Corps Base - Camp Lejeune
Legally Responsible
Talia Barraco
Individual
NC Reference No.
NCG01-2020-0536
E&SC Plan ID
ONSLO-2020-025
Original NOI
21726
Tracking No.
Date COC Issued
2/17/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 8/18/2020
Inspection Approval

Project Close-out RTAMS TLZ Bluebird - 8.18.20 - close.pdf 256.15KB
Approval Mist be RYforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording 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 notto 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 * Talia Prendergast
Title * PWD Civil Engineer
Organization* MCB Camp Lejeune
Date * 11 /12/2020
Email for [e-mail]
Confirmation *
Contact Telephone * [phone] x3242
NOT Certification 19-0166_TLZBluebird_NOT_11.09.20.pdf 29.45KB
Form Mist be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]