NCC200295_Notice of Termination_20210107

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/7/2021 12:25:35 PM (NOT Submittal)
Approve by Morman, Alaina 1/8/2021 4:48:05 PM (NOT Request Review- NCC200295)
• The task was assigned to Morman, Alaina. The due date is: January 12, 2021 5:00 PM
1 /7/2021 12:25 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200295
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
Willard Solar
Address
455 Church Street, Willard, NC
County
Pender
Latitude
34.7028
Longitude
-77.9711
Permittee Listed
Horne Brothers Construction INC
Legally Responsible
C. Jackson Horne
Individual
NC Reference No.
NCG01-2020-0295
E&SC Plan ID
PENDE-2019-020
Original NOI
21047
Tracking No.
Date COC Issued
2/5/2020
Prior Rescission
Date populates only if OOCwas already rescinded at tirre of submittal.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 Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 12/18/2020
Inspection Approval
Project Close-out Closeout Inspection Report - Willard.pdf 57.76KB
Approval Mast be FDFfornat
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
r
Type Name* C. Jackson Horne
Title * President
Organization* Horne Brothers Construction, Inc.
Date * 01 /07/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9103230320
NOT Certification NOT Certification Form.pdf
Form Mast 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 CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
378.62KB