NCC190703_Notice of Termination_20201221

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/21/2020 9:21:04 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/22/2020 8:24:53 AM (NOT Request Review- NCC190703)
p Permittee provided NOT Certification form via e-mail.
• The task was assigned to Georgoulias, Bethany. The due date is: December 24, 2020 5:00 PM
12/21 /2020 9:21 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190703
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
PAID
2021 Annual Fee Status
N/A
Information associated
with this permit:
Project Name
China Grove Medical Office Addition
Address
1965 South Highway 29, China grove, NC
County
Rowan
Latitude
35.5800
Longitude
-80.5500
Permittee Listed
Novant Health
Legally Responsible
Matthew Stiene
Individual
NC Reference No.
NCG01-2019-0703
E&SC Plan ID
N/A
Original NOI
12729
Tracking No.
Date COC Issued
6/24/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 5/14/2020
Inspection Approval
Project Close-out Sedimentation report.pdf 376.75KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, 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 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 may include a fine not to exceed ten thousand
dollars ($10,000).
rJ 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* Matthew Stiene
Title * Vice President Construction and Engineering
Organization* Novant Health
Date * 12/21 /2020
Email for [e-mail]
Confirmation *
Contact Telephone* 704-316-4351
NOT Certification NOI.pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
232.49KB