NCC201342_Notice of Termination_20210521

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/21/2021 9:05:19 AM (NOT Submittal)
Approve by Morman, Alaina 5/23/2021 1:38:08 PM (NOT Request Review- NCC201342)
• The task was assigned to Morman, Alaina. The due date is: May 26, 2021 5:00 PM 5/21/2021 9:05 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201342
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
fvby 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
Davie County Government Center
Address
182 Farmington Rd, Mocksville, NC
County
Davie
Latitude
35.9549
Longitude
-80.5308
Permittee Listed
County of Davie
Legally Responsible
John Eller
Individual
NC Reference No.
NCG01-2020-1342
E&SC Plan ID
DAVIE-2020-010
Original NOI
23769
Tracking No.
Date COC Issued
4/7/2020
Prior Rescission
Cate populates only if OOC was already rescinded at tirre of submittal.
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 bePIDFformat
Project Close-out Information:
Final Close-out 5/19/2021
Inspection Approval
Project Close-out Inspection Report 05-19-21 (DAVIE-2020-
Approval 125.73KB
010). F INALREPORT. pdf
Documentation
Mist be Ft7Fforrrat
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 of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
I7 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* BRADLEY D BLACKWELDER
Title * PROJECT MANAGER
Organization * COLITY OF DAVIE
Date * 05/21 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 3369091040
NOT Certification NCG01.NOT FORM.pdf 32.86KB
Form Mist be PIDF Format

Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?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