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HomeMy WebLinkAboutNCC200039_Notice of Termination_20210106Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 1/6/2021 11:15:35 AM (NOT Submittal) Approve by Morman, Alaina 1/6/2021 11:24:12 AM (NOT Request Review- NCC200039) • The task was assigned to Morman, Alaina. The due date is: January 11, 2021 5:00 PM 1/6/2021 11:15 AM 1 � NORTH CAROLINA Enrlronmenral Quallly Certificate of NCC200039 Coverage (COC) Enter the Certificate of Coverage Nmber No.* 2020 Annual Fee Status 2021 Annual Fee Status OPEN May be blank (if not yet billed). Information associated with this permit: Project Name 4020 Strickland Farm Rd Address 4020 Strickland Farm Road, Raleigh, NC County Wake Latitude 35.8290 Longitude -78.5150 Permittee Listed Scott A. Smith & Monica W. Shabo Legally Responsible Scott Smith Individual NC Reference No. NCG01-2020-0039 E&SC Plan ID LDG-022904-2019 Original NOI 20144 Tracking No. Date COC Issued 1/7/2020 Prior Rescission Date populates only if COCwas already rescinded at time of submittal.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 * r Mistake or Invalid Coverage r Other Addional Nbre information about the basis of this request, if needed. Explanation Supporting upload Supporting Documentation if applicable. Documentation NlastbeRYforrrat Project Close-out Information: Final Close-out 10/20/2020 Inspection Approval Project Close-out Certificate of Completion.pdf 58.82KB Approval Must 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 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 of the Commission implementing this Artcle 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* Scott Smith Title * Owner Organization* Homeowner Date * 01 /06/2021 Email for sasmith622@nc.rr.com Confirmation * Contact Telephone* 919-524-9699 NOT Certification SKM_C36821040811140.pdf 59.27KB Form Mist be FDF Forrrst 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 sasmith622@nc.rr.com Original Site Contact CCd on Notificaiton Errails Email ticlarryl@gmail.com