NCC201625_Notice of Termination_20210406

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/6/2021 10:39:33 AM (NOT Submittal)
Approve by Morman, Alaina 4/7/2021 3:01:07 PM (NOT Request Review- NCC201625)
• The task was assigned to Morman, Alaina. The due date is: April 9, 2021 5:00 PM 4/6/2021 10:39 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201625
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
Silas Haynes
Address
1321 Medlin Road, Monroe, NC
County
Union
Latitude
34.9641
Longitude
-80.5239
Permittee Listed
Silas Haynes
Legally Responsible
Silas Haynes
Individual
NC Reference No.
NCG01-2020-1625
E&SC Plan ID
20-00201623
Original NOI
24653
Tracking No.
Date COC Issued
4/22/2020
Prior Rescission
Date populates only if COCwas already rescinded at time of submittal.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 Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation NlastbeRYforrrat

Project Close-out Information:
Final Close-out 4/1/2021
Inspection Approval
Project Close-out Eroison Control Permit Closed Out.pdf 47.48KB
Approval NCG01-eNOT-Certification-Form-20210305-
Docume ntation 741.13KB
DEMLR-SW.pdf
Wst 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 Artide; 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* Silas L Haynes
Title * Owner
Organization* Owner
Date * 04/06/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7048068492
NOT Certification NCG01-eNOT-Certification-Form-20210305-
Form 741.13KB
DEMLR-SW.pdf
Mast be FDF Format
Is this COC Already Ensure this COChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
0Cd on Notification Errails
0Cd on Notification Errails
[e-mail]

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