NCC200455_Notice of Termination_20210609

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/9/2021 5:02:40 PM (NOT Submittal)
Approve by Morman, Alaina 6/10/2021 11:39:43 AM (NOT Request Review- NCC200455)
• The task was assigned to Morman, Alaina. The due date is: June 14, 2021 5:00 PM 6/9/2021 5:02 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200455
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
fvby be blank (if not yet billed).
Information associated with this permit:
Project Name
PNG Line 328 Relocation A
Address
White Rock Road, Winston-Salem, NC
County
Forsyth
Latitude
36.1785
Longitude
-80.2157
Permittee Listed
Piedmont Natural Gas
Legally Responsible
Sanu Odugbesan
Individual
NC Reference No.
NCG01-2020-0455
E&SC Plan ID
FORSY-2020-013
Original NOI
21488
Tracking No.
Date COC Issued
2/6/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 ivbre information about the basis of this request, if needed.
Explanation Project complete and permanent ground
cover established. Please see attached final
inspection report dated 6/9/2021.

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 6/9/2021
Inspection Approval
Project Close-out NCC200455 Closure Inspection Report (FORSY-
Approval 247.36KB
2020-013).pdf
Documentation
Mast be PDFformat
North Carolina General Statute 143-215.613 (i) 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 Artide 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 Artide 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).
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
Type Name* Adam Pollak
Title * Project Manager
Organization* Piedmont Natural Gas
Date * 06/09/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9524562648
NOT Certification NCC200455 NOT Certification Form Line 328
Form 33.33KB
Relo.pdf
Mast be FDF Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) Alicia. [e-mail]
Original Permittee 0Cd on Wification BTails
Email [e-mail]

Original Site Contact GCd on Wificaiton BTails
Email [e-mail]