NCC190683_Notice of Termination_20201118

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/18/2020 3:27:57 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/19/2020 8:38:32 AM (NOT Request Review- NCC190683)
• The task was assigned to Georgoulias, Bethany. The due date is: November 23, 2020 5:00 PM
11/18/2020 3:28 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190683
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
SECU Clayton Branch
Address
37 Briarcliff Drive, Clayton, NC
County
Johnston
Latitude
35.6442
Longitude
-78.4220
Permittee Listed
State Employees' Credit Union
Legally Responsible
Paul Barbour
Individual
NC Reference No.
NCG01-2019-0683
E&SC Plan ID
JC# 19-032-P
Original NOI
12679
Tracking No.
Date COC Issued
6/21/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 11/4/2020
Inspection Approval

Project Close-out Johnston County Sedimentation Inspection
Approval 533.5KB
Report.pdf
Documentation
SECU Clayton 20200812 Cert of Occupncy.pdf 523.95KB
Mist be FDFforrrat
North Carolina General Statute 143-215.613 (i) 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 Artide; 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 device 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 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
01?lV,t-
Type Name* Vice President
Title * Vice President Property Construction
Organization* State Employees' Credit Union
Date * 11 /18/2020
Email for Paul. [e-mail]
Confirmation *
Contact Telephone* 919-856-3340
NOT Certification Notice of Termination Certification Form.pdf
Form NUst be RY Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCdonWificationBmils
Email [e-mail]
Original Site Contact 0Cd on Notificaiton BTails
Email [e-mail]
606.36KB