NCC202016_Notice of Termination_20210505

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/5/2021 9:53:00 AM (NOT Submittal)
Approve by Georgoulias, Bethany A 5/6/2021 1:10:54 PM (NOT Request Review- NCC202016)
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 5/6/2021 9:46 AM
The task was assigned to Morman, Alaina. The due date is: May 10, 2021 5:00 PM 5/5/2021 9:53 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202016
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
TL 182 Removal Phase 1
Address
Greensville Blvd, Greensville, NC
County
Pitt
Latitude
35.6199
Longitude
-77.3326
Permittee Listed
Virginia Electric and Power Company
Legally Responsible
Mark Allen
Individual
NC Reference No.
NCG01-2020-2016
E&SC Plan ID
Pitt-2020-011
Original NOI
25502
Tracking No.
Date COC Issued
5/15/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 4/28/2021
Inspection Approval
Project Close-out 20210428 cover letter & sed insp report PITT-2020-
Approval 315.2KB
011 TL 182 Removal Pha.... 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 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 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 Article 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* Donald Hoover
Title * Manager, Electric Transmission and Substation Construction
Organization * Virginia Electric and Power Company
Date * 05/05/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 8047731046
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 CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]
596.22KB