NCC200958_Notice of Termination_20210304

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/4/2021 4:34:15 PM (NOT Submittal)
Approve by Morman, Alaina 3/8/2021 4:40:46 PM (NOT Request Review- NCC200958)
• The task was assigned to Morman, Alaina. The due date is: March 9, 2021 5:00 PM 3/4/2021 4:34 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200958
Coverage (COC)
Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
N/hy be blank (if not yet billed).
Information associated
with this permit:
Project Name
Davie Campus Parking Lot Expansion
Address
1205 S Salisbury St., Mocksville, NC
County
Davie
Latitude
35.8709
Longitude
-80.5555
Permittee Listed
Davidson County Community College
Legally Responsible
Keith Raker
Individual
NC Reference No.
NCG01-2020-0958
E&SC Plan ID
DAVIE-2020-011
Original NOI
22937
Tracking No.
Date COC Issued
3/12/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Addional We inforrration about the basis of this request, if needed.
Explanation Site visit was performed on November 24,
2020 and closeout letter was sent on
November 25, 2020

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 11/25/2020
Inspection Approval
Project Close-out Inspection Report 11-24-20 (DAVIE-2020-011).pdf 130.72KB
Approval Mast be FDFformat
Documentation
North Carolina General Statute 143-215.613 (i) 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 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* Keith Raker
Title * Director, Physical Plant Services
Organization * Davidson -Davie Community College
Date * 03/04/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-224-4651
NOT Certification Storm water permit - Davie parling lot.pdf 29.73KB
Form Mast 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 BTails
Email [e-mail]

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