NCC200070_Notice of Termination_20210208

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/8/2021 11:49:25 AM (NOT Submittal)
Approve by Morman, Alaina 2/9/2021 4:25:29 PM (NOT Request Review- NCC200070)
• The task was assigned to Morman, Alaina. The due date is: February 11, 2021 5:00 PM
2/8/2021 11:49 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200070
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
Altapass Baptist Rec Park
Address
Altapass Highway and Overlook Drive, Spruce Pine, NC
County
Mitchell
Latitude
35.9085
Longitude
-82.0613
Permittee Listed
Altapass Baptist Church, Inc.
Legally Responsible
Dr. Marcus Benfield
Individual
NC Reference No.
NCG01-2020-0070
E&SC Plan ID
Mitch 2019-003
Original NOI
20233
Tracking No.
Date COC Issued
1/13/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 1/22/2021
Inspection Approval
Project Close-out 01 22 21 Inspection Report (1) Closeout.pdf 306.45KB
Approval Mast 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* Dr. Marcus Benfield
Title * President & CEO
Organization* Altapass Baptist Church, Inc.
Date * 02/08/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 18287650660
NOT Certification not SCAN.pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Notification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
744.54KB