NCC205611_Notice of Termination_20210609

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/9/2021 9:16:07 PM (NOT Submittal)
Approve by Morman, Alaina 6/10/2021 11:22:55 AM (NOT Request Review- NCC205611)
• The task was assigned to Morman, Alaina. The due date is: June 14, 2021 5:00 PM 6/9/2021 9:16 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC205611
Coverage (COC) Enter the Certificate of Coverage Nimber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Veit Residence - 3911 Austin Valley Dr, Lenoir, NC
Address
3911 Austin Valley Drive, Lenoir, NC
County
Caldwell
Latitude
36.0000
Longitude
-82.0000
Permittee Listed
William Veit
Legally Responsible
William Veit
Individual
NC Reference No.
NCG01-2020-5611
E&SC Plan ID
CALDW-2021-003
Original NOI
38181
Tracking No.
Date COC Issued
12/30/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 5/10/2021
Inspection Approval
Project Close-out Inspection Report 5-10-2021.pdf 370.15KB
Approval Mast be FDFfornat
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 deice 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* William Veit
Title * Owner
Organization* William Viet
Date * 06/09/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 828-446-2525
NOT Certification Veit Residence Executed NOT Certifiction Form.pdf 501.52KB
Form Mast be FDF Fornat
Is this COC Already Ensure this OCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Erails
CCd on Notification Erails
[e-mail]
Original Site Contact OCd on Notificaiton 57ails
Email [e-mail]