NCC190064_Notice of Termination_20210520

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/20/2021 9:55:01 PM (NOT Submittal)
Approve by Morman, Alaina 5/23/2021 12:52:31 PM (NOT Request Review- NCC190064)
• The task was assigned to Morman, Alaina. The due date is: May 25, 2021 5:00 PM 5/20/2021 9:55 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190064
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status PAST DUE
Nby be blank (iF not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Review step) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Testoff Residence
Address
3405 Myrtle Grove Drive, Gibsonville, NC
County
Guilford
Latitude
36.1377
Longitude
-79.5733
Permittee Listed
James Randall General Contractor
Legally Responsible
James Randall
Individual
NC Reference No.
NCG01-2019-0064
E&SC Plan ID
19-04-GCRP-02979
Original NOI
10227
Tracking No.
Date COC Issued
4/18/2019
Prior Rescission
Date populates only if OOCwas already rescinded at tirre of subaittal.
Date
Reason for Rescission/Termination Request:

Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a newCOC)
Coverage * r Mistake or Invalid Coverage
f Other
Add ional We information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Ibcurrentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 5/3/2021
Inspection Approval
Project Close-out Surety Release Guilford County.PDF 293.62KB
Approval Mist be FDFformat
Documentation
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).
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
)aW� WAill
Type Name* James M Randall, Jr
Title * Owner
Organization* James Randall General Contractor
Date * 05/20/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-337-2325
NOT Certification NOT Certification Form 5.20.21.PDF 361.23KB
Form Mist be FDF Format

Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email 0Cd on Notification Errails
(Optional) [e-mail]
Original Permittee 0Cd onNiotificationBmils
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]