NCC192587_Notice of Termination_20201225

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/25/2020 4:41:43 PM (NOT Submittal)
Approve by Georgoulias, Bethany 1/4/2021 9:12:24 AM (NOT Request Review- NCC192587)
• The task was assigned to Georgoulias, Bethany. The due date is: December 30, 2020 5:00 PM
12/25/2020 4:41 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192587
Coverage (COC) Enter the Certificate of Coverage Nimber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Mt. Vernon Baptist Church
Address
1156 Northbrook III School Road, Vale, NC
County
Lincoln
Latitude
35.5334
Longitude
-81.4800
Permittee Listed
Mt. Vernon Baptist Church
Legally Responsible
Allen Gantt
Individual
NC Reference No.
NCG01-2019-2587
E&SC Plan ID
19-COM-17
Original NOI
17918
Tracking No.
Date COC Issued
10/31/2019
Prior Rescission
Date populates only if OOC was already rescinded at tirre of submittal.
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 Docurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 12/23/2020
Inspection Approval
Project Close-out DOC122320.pdf 464.49KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) 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 Article; 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 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 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* Alan L Gantt
Title * Project Manager
Organization * Mount Vernon Baptist Church
Date * 12/25/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 7044723524
NOT Certification NOT Cert Form.pdf 363.48KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Erails
CCd on Notification Bmils
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]