NCC201960_Notice of Termination_20210105

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/5/2021 1:25:49 PM (NOT Submittal)
Approve by Morman, Alaina 1/6/2021 11:33:39 AM (NOT Request Review- NCC201960)
• The task was assigned to Morman, Alaina. The due date is: January 8, 2021 5:00 PM
1 /5/2021 1:26 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201960
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
FY20 Short Water Line Extensions Projects Phase 1
Address
6901-7317 Pinewood Forest Dr.; 6750-7111 Plainview Rd., Indian Trail, NC
County
Union
Latitude
35.0291
Longitude
-80.6595
Permittee Listed
Union County Public Works
Legally Responsible
John Shutak
Individual
NC Reference No.
NCG01-2020-1960
E&SC Plan ID
UNION-2020-065
Original NOI
25293
Tracking No.
Date COC Issued
5/13/2020
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Date populates only if OOC was already rescinded at tirre of submittal.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 *
U 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 12/31/2020
Inspection Approval
Project Close-out 20200104_NCDEQ_ESC_InspectionReport. pdf 1.46MB
Approval Mist 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
J4& lAk*
Type Name* John Shutak
Title * Director of Engineering
Organization * Union County Government Public Works
Date * 01 /05/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704.283.3651
NOT Certification NCG01-eNOT-Certification-Form-20201215-
Form DEMLR-SW Executed.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on Wtificaiton Errails
Email [e-mail]
1.91 MB