NCC190250_Notice of Termination_20210603

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/3/2021 11:11:06 AM (NOT Submittal)
Approve by Morman, Alaina 6/9/2021 11:36:06 AM (NOT Request Review- NCC190250)
• The task was assigned to Morman, Alaina. The due date is: June 8, 2021 5:00 PM 6/3/2021 11:11 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190250
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
K/hy be blank (if not yet billed).
Information associated with this permit:
Project Name
Pluris webb Creek WWTP
Address
250 Zachary Lane, Hubert, NC
County
Onslow
Latitude
34.6703
Longitude
-77.2020
Permittee Listed
Pluris Webb Creek, LLC
Legally Responsible
Maurice Gallarda
Individual
NC Reference No.
NCG01-2019-0250
E&SC Plan ID
ONSLO-2019-043
Original NOI
10907
Tracking No.
Date COC Issued
5/10/2019
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Cate populates only if COCwas already rescinded at time of submittal.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 5/5/2021
Inspection Approval
Project Close-out North Carolina Department of Environmental Quality
Approval 530.81 KB
Webb Creek Close out of Storm water.pdf
Documentation
Mast 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* Randy Hoffer
Title * Regional Manager
Organization* Pluris Webb Creek
Date * 06/03/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 910-852-0630
NOT Certification NOT Form Pluris WC 060321.pdf
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton 57ails
Email [e-mail]
719.17KB