NCC200398_Notice of Termination_20210210

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/10/2021 2:54:51 PM (NOT Submittal)
Approve by Morman, Alaina 2/11/2021 5:01:35 PM (NOT Request Review- NCC200398)
• The task was assigned to Morman, Alaina. The due date is: February 15, 2021 5:00 PM
2/10/2021 2:55 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200398
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
Islander Drive Street Improvements - Town of Emerald Isle
Address
NC Highway 58 & Islander Drive, Town of Emerald Isle, NC
County
Carteret
Latitude
34.6585
Longitude
-77.0559
Permittee Listed
Town of Emerald Isle
Legally Responsible
Matthew Zapp
Individual
NC Reference No.
NCG01-2020-0398
E&SC Plan ID
CARTE-2020-010
Original NOI
21295
Tracking No.
Date COC Issued
2/3/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 We information about the basis of this request, if needed.
Explanation Following a notice from the state, a final
closeout inspection was received in Feb
2021.

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 2/10/2021
Inspection Approval
Project Close-out Inspection - 2.9.21 - Closed.pdf
Approval Mast be FDFformat
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
79.83KB
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Artide 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 device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 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* Matthew Zapp
Title * Town Manager
Organization* Town of Emerald Isle
Date * 02/10/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9106580974
NOT Certification Notice of Termination Form NOT DEQ 2.10.21.pdf 407.46KB
Form Mist be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) [e-mail]
Original Permittee CCd on Notification Biails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]