NCC201829_Notice of Termination_20210505

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/5/2021 8:53:46 AM (NOT Submittal)
Approve by Georgoulias, Bethany A 5/6/2021 6:48:27 AM (NOT Request Review- NCC201829)
p Permittee inadvertently uploaded inspection report twice with this request but forwarded the NOI
Certification form via email (will be added to the file).
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 5/5/2021 1:02 PM
The task was assigned to Morman, Alaina. The due date is: May 10, 2021 5:00 PM 5/5/2021 8:53 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201829
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
N/hy be blank (if not yet billed).
Information associated with this permit:
Project Name
Coastal Christian High School Building Addition
Address
1150 Kings Highway, Wilmington, NC
County
New Hanover
Latitude
34.1347
Longitude
-77.8897
Permittee Listed
Myrtle Grove Presbyterian Church
Legally Responsible
Wilbur Davis
Individual
NC Reference No.
NCG01-2020-1829
E&SC Plan ID
GP #10-97 Revision #17
Original NOI
25028
Tracking No.
Date COC Issued
5/6/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 3/31/2021
Inspection Approval
Project Close-out Final Field Inspection Report- Coastal Christian HS
Approval 761.65KB
Addition, GP#10-97 Rev.17.pdf
Documentation
Mist be FDFforrrat
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 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 deice or method required to be operated or maintained under this Artide or rules ofthe
Commission implementing this Article 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* Wilbur Davis
Title * Chair BFPC
Organization* Myrtle Grove Presyterian Church
Date * 05/05/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9107916179
NOT Certification Final Field Inspection Report- Coastal Christian HS
Form 761.65KB
Addition, GP#10-97 Rev.17.pdf
Mist be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonNotificationBmils
Email wdavis301 @bellsouth.net
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]