NCC204530_Notice of Termination_20210322

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/22/2021 5:41:15 PM (NOT Submittal)
Approve by Morman, Alaina 3/25/2021 3:36:40 PM (NOT Request Review- NCC204530)
• The task was assigned to Morman, Alaina. The due date is: March 25, 2021 5:00 PM
3/22/2021 5:41 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC204530
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Bostic Landfill
Address
389 W Church Street, Bostic, NC
County
Rutherford
Latitude
35.0000
Longitude
-82.0000
Permittee Listed
Buckeye Elm Contracting, LLC
Legally Responsible
Joel Miller
Individual
NC Reference No.
NCG01-2020-4530
E&SC Plan ID
RUTHE-2020-011
Original NOI
32630
Tracking No.
Date COC Issued
10/8/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out
3/4/2021
Inspection Approval
Project Close-out
HPSCAN_ 20210322204257706_2021-03-
Approval
468.59KB
22_204354378. pdf
Documentation
HPSCAN 20210316212132818 2021-03-
1.16MB
16_212229597. pdf
Inspection Report 3-4-21.pdf 297.44KB
Mast be FDFforrrat
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* Joel Miller
Title * Principal
Organization* Buckeye -Elm Contracting LLC
Date * 03/22/2021
Email for [e-mail]
Confirmation *
Contact Telephone * 1 614 400 5460
NOT Certification HPSCAN_ 20210322204257706 2021-03-
Form 468.59KB
22_204354378. pdf
HPSCAN 20210316212132818 2021-03-
1.16MB
16_212229597. pdf
Mast be FDF Forrret
Is this COC Already Ensure this COChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Bmils
(Optional) [e-mail]

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