NCC191295_Notice of Termination_20201230

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/30/2020 9:34:49 PM (NOT Submittal)
Approve by Georgoulias, Bethany 1/4/2021 7:24:56 AM (NOT Request Review- NCC191295)
• The task was assigned to Georgoulias, Bethany. The due date is: January 4, 2021 5:00 PM
12/30/2020 9:34 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC191295
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Advent Health Care Office
Address
HWY 108, Columbus, NC
County
Polk
Latitude
35.2388
Longitude
-82.2225
Permittee Listed
GEORGE G & TONYA S KIM
Legally Responsible
GEORGE G & TONYA S KIM
Individual
NC Reference No.
NCG01-2019-1295
E&SC Plan ID
POLK 2019-006
Original NOI
14555
Tracking No.
Date COC Issued
8/12/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
r 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 12/4/2019
Inspection Approval
Project Close-out Advent NOT.pdf 728.57KB
Approval Close -Out Inspection Report 12-4-19 (1).pdf 27.17KB
Documentation
Mast be Ft7Fforrrat
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 device 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).
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 * George G Kim
Title * Owner
Organization* Advent Internal Medicine
Date * 12/30/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 828-674-8101
NOT Certification Advent NOT.pdf
Form Close -Out Inspection Report 12-4-19 (1).pdf
Mast be RY Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonWificationBails
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errnils
Email [e-mail]
728.57KB
27.17KB