NCC202454_Notice of Termination_20210609

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/9/2021 4:32:27 PM (NOT Submittal)
Approve by Morman, Alaina 6/10/2021 11:19:23 AM (NOT Request Review- NCC202454)
• The task was assigned to Morman, Alaina. The due date is: June 14, 2021 5:00 PM 6/9/2021 4:32 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202454
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
2312 Mizpah Church Road - Taylor Property
Address
2312 Mizpah Church Road, Tobaccoville, NC
County
Forsyth
Latitude
36.2142
Longitude
-80.3334
Permittee Listed
Taylor Weber
Legally Responsible
Taylor Weber
Individual
NC Reference No.
NCG01-2020-2454
E&SC Plan ID
EN2000085
Original NOI
26830
Tracking No.
Date COC Issued
6/11/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 We information about the basis of this request, if needed.
Explanation work is completed
Supporting upload Supporting Qbcurrentation if applicable.
Documentation Mist beRYforrrat

Project Close-out Information:
Final Close-out 6/9/2021
Inspection Approval
Project Close-out sir TAYLOR RESIDENCE 6-8-21 n.o.t.pdf 82.71 KB
Approval Mast be FDFforrrat
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 Amide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this 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 Article or rules of the
Commission implementing this Artcle 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* Taylor Weber
Title * Owner
Organization * work is completed
Date * 06/09/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7042395121
NOT Certification 20210609_160650.pdf 315.58KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this OCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
OCd on Notification Errails
[e-mail]
CCd on Notification Erails
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]