NCC200305_Notice of Termination_20210106

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/6/2021 12:22:28 PM (NOT Submittal)
Approve by Morman, Alaina 1/7/2021 3:18:43 PM (NOT Request Review- NCC200305)
• The task was assigned to Morman, Alaina. The due date is: January 11, 2021 5:00 PM
1 /6/2021 12:22 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200305
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
K/hy be blank (if not yet billed).
Information associated
with this permit:
Project Name
Lane 2 Solar, LLC
Address
785 Old Smithfield Road, Goldsboro, NC
County
Wayne
Latitude
35.4012
Longitude
-78.0520
Permittee Listed
Horne Brothers Construction INC
Legally Responsible
C. Jackson Horne
Individual
NC Reference No.
NCG01-2020-0305
E&SC Plan ID
Wayne-2019-019
Original NOI
21050
Tracking No.
Date COC Issued
1/27/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.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 IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation MstbeRYforrrat

Project Close-out Information:
Final Close-out 6/10/2020
Inspection Approval
Project Close-out Closeout Inspection WAYNE-2019-019 Lane Solar
Approval 2.pdf 133.06KB
Documentation
Mist be FDFforrrat
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
r
Type Name* C. Jackson Horne
Title * President
Organization* Horne Brothers Construction, Inc.
Date * 01 /06/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9103230320
NOT Certification NOT Request Form - Construction Stormwater
Form NCG01 o.pdf
Mist be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email OCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]
388.78KB