NCC191950_Notice of Termination_20210112

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/12/2021 8:17:05 AM (NOT Submittal)
Approve by Morman, Alaina 1/13/2021 1:33:41 PM (NOT Request Review- NCC191950)
• The task was assigned to Morman, Alaina. The due date is: January 15, 2021 5:00 PM
1/12/2021 8:17 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191950
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status PAST DUE
2021 Annual Fee Status Nbybeblank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Reviewstep) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Jim Johnson Road Waterline
Address
Jim Johnson Road, Kannapolis, NC
County
Cabarrus
Latitude
35.0000
Longitude
-81.0000
Permittee Listed
City of Kannapolis
Legally Responsible
Beth Hassenfritz
Individual
NC Reference No.
NCG01-2019-1950
E&SC Plan ID
CABAR-2020-002
Original NOI
15971
Tracking No.
Date COC Issued
9/19/2019
Prior Rescission
Cate populates only if CDC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
C Project Closed -Out
Termination of
Q Sale (Another Owner/Operator will apply for a new COC)
Coverage *
a Mistake or Invalid Coverage
0 Other

Add ional Nbre infornation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcurrentation if applicable.
Documentation Mist bePDFforrat
Project Close-out Information:
Final Close-out 12/30/2020
Inspection Approval
Project Close-out CABAR-2020-002_12.30.2020.pdf 58.08KB
Approval NUst be Ft7Ffornat
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 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
ffa-4 wlzlfli
Type Name* Beth Hassenfritz
Title * Assistant Director of Engineering
Organization * City of Kannapolis
Date * 01 /12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704-920-4235
NOT Certification NCG01 NOT Certification Form Signed.pdf 372.49KB
Form Mist be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification En -ails
(Optional)

Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact GCd on Notificaiton Errnils
Email [e-mail]