NCC200982_Notice of Termination_20210427

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/27/2021 10:46:54 AM (NOT Submittal)
Approve by Morman, Alaina 4/29/2021 8:58:56 AM (NOT Request Review- NCC200982)
• The task was assigned to Morman, Alaina. The due date is: April 30, 2021 5:00 PM
4/27/2021 10:47 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200982
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
PAID
Nt3y be blank (if not yet billed).
Information associated
with this permit:
Project Name
Watson Wood Works
Address
780 Megahertz Drive, Winston-Salem, NC
County
Forsyth
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Watson Woodworks
Legally Responsible
Jesse Watson
Individual
NC Reference No.
NCG01-2020-0982
E&SC Plan ID
EN2000017
Original NOI
23025
Tracking No.
Date COC Issued
3/13/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 Mist beRYforrrat

Project Close-out Information:
Final Close-out 4/23/2021
Inspection Approval
Project Close-out Sedimentation Inspection.pdf 76.73KB
Approval Certificate of Completion.pdf 57.14KB
Documentation
Mist be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed 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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which may include 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* Jesse Watson
Title * President
Organization* Watson Wood Works
Date * 04/27/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-793-1807
NOT Certification NCG01 Notice of Termination (NOT) Certification
Form Form.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email OCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton F-rails
Email [e-mail]
96.73KB