NCC201404_Notice of Termination_20210416

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/16/2021 11:37:32 AM (NOT Submittal)
Approve by Morman, Alaina 4/19/2021 4:38:23 PM (NOT Request Review- NCC201404)
• The task was assigned to Morman, Alaina. The due date is: April 21, 2021 5:00 PM
4/16/2021 11:37 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201404
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
Mixed Use Development Utility Improvement Project
Address
120 Virginia Place, High Point, NC
County
Guilford
Latitude
35.9573
Longitude
-80.0092
Permittee Listed
City of High Point
Legally Responsible
Terry Houk
Individual
NC Reference No.
NCG01-2020-1404
E&SC Plan ID
GUILF-2019-001
Original NOI
24023
Tracking No.
Date COC Issued
4/17/2020
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Date populates only if COCwas already rescinded at time of submittal.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 4/9/2021
Inspection Approval
Project Close-out 4-7-2021 Inspection Report GUILF-2019-001 North
Approval Elm Utility Improvements, Mixed Use Development, 92.58KB
Documentation
Amendments.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* Terry Houk
Title * Public Services Director
Organization * City of High Point
Date * 04/16/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-883-3218
NOT Certification NCG01-eNOT-Certification-Form-20210305-
Form 356.7KB
DEMLR-SW Signed.pdf
Mast be FDF Format
Is this COC Already Ensure this COChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCd on Wification Errails
Email [e-mail]

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