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HomeMy WebLinkAboutNCC201077_Notice of Termination_20210322Action History (UTC-05:00) Eastern Time (US & Canada) Subrrit by Anonymous User 3/22/2021 2:56:32 PM (NOT Submittal) Approve by Morman, Alaina 3/25/2021 10:30:28 AM (NOT Request Review- NCC201077) • The task was assigned to Morman, Alaina. The due date is: March 25, 2021 5:00 PM 3/22/2021 2:56 PM 1 � NORTH CAROLINA Enrlronmenral Quallly Certificate of NCC201077 Coverage (COC) Enter the Certificate of Coverage Nmber No.* 2020 Annual Fee Status 2021 Annual Fee Status OPEN May be blank (if not yet billed). Information associated with this permit: Project Name Well Spring Campus Parking Expansion Address 3560 Wildflower Drive, Greensboro, NC County Guilford Latitude 36.0000 Longitude -80.0000 Permittee Listed Well Spring Retirement Community, Inc. Legally Responsible Stephen Fleming Individual NC Reference No. NCG01-2020-1077 E&SC Plan ID 2983 Original NOI 23153 Tracking No. Date COC Issued 3/24/2020 Prior Rescission Cate populates only if COCwas already rescinded at time of submittal.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 obtained 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 3/12/2021 Inspection Approval Project Close-out Storm water close out New Parkong.pdf 31.18KB Approval Must be FDFfornat 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* Jerry Hayes Title * Vice President of Construction Services Organization* Well -Spring Retirement Community, Inc. Date * 03/22/2021 Email for jhayes@well-spring.org Confirmation * Contact Telephone* 3362157984 NOT Certification Signed by Steve NOT.pdf Form Storm water close out New Parkong.pdf Mist be FDF Fornat Is this COC Already Ensure this CCChas not been rescinded since subrrittal! Rescinded? Additional Email CCd on Notification En -ails (Optional) Original Permittee CCd onNotificationBmils Email sfleming@well-spring.org Original Site Contact CCd on Notificaiton Errails Email jhayes@well-spring.org 39.17KB 31.18KB