NCC200608_Notice of Termination_20210210

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/10/2021 9:40:51 AM (NOT Submittal)
Approve by Morman, Alaina 2/11/2021 5:04:25 PM (NOT Request Review- NCC200608)
• The task was assigned to Morman, Alaina. The due date is: February 15, 2021 5:00 PM
2/10/2021 9:40 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200608
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
Paul Lewis Waste Area
Address
Little Savannah Road, Webster, NC
County
Jackson
Latitude
35.0000
Longitude
-83.0000
Permittee Listed
Site Development Corporation
Legally Responsible
Andy Southards
Individual
NC Reference No.
NCG01-2020-0608
E&SC Plan ID
20-102
Original NOI
21958
Tracking No.
Date COC Issued
2/19/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 2/5/2021
Inspection Approval
Project Close-out 20-102 Paul Lewis Waste Site report.pdf 347.56KB
Approval 20-102 cert.pdf 50.46KB
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording 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 notto 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
6?'zlc_ef 0% Afew
Type Name* Caleb Johnson
Title * Project Manager
Organization* Site Development Corporation
Date * 02/10/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 8284479088
NOT Certification NOT Ceritification Form.pdf
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
477.89KB