NCC202330_Notice of Termination_20201209

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/9/2020 2:42:15 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/9/2020 4:55:11 PM (NOT Request Review- NCC202330)
• The task was assigned to Georgoulias, Bethany. The due date is: December 14, 2020 5:00 PM
12/9/2020 2:42 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202330
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee
Status
Information associated
with this permit:
Project Name
AT&T Harmony, NC (A01SVLP)
Address
Olin Road, Harmony, NC
County
Iredell
Latitude
35.9499
Longitude
-80.8407
Permittee Listed
BellSouth Telecommunications, LLC
Legally Responsible
Michael Wiggin
Individual
NC Reference No.
NCG01-2020-2330
E&SC Plan ID
IREDE-2020-012
Original NOI
26477
Tracking No.
Date COC Issued
6/5/2020
Prior Rescission
Cute populates only if COCwas already rescinded at tirre of submttal.
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 *
r Mistake or Invalid Coverage
r Other
Addional IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting DDcurrentation if applicable.
Documentation NLstbeFOFformat
Project Close-out Information:

Final Close-out 11/5/2020
Inspection Approval
Project Close-out IREDE-2020-012_AT&T Harmony
Approval 57.6KB
CO_11.5.2020.pdf
Documentation
Mast be R7Fforrrat
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 Arficle; orwho 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 Arficle 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* Michael Wiggin
Title * Director C&E
Organization* Bellsouth Telecommunications, LLC
Date * 12/09/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 336-549-4868
NOT Certification Signed NOT Form _20NC03.pdf 41.28KB
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Notification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]