NCC190447_Notice of Termination_20210618

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/18/2021 9:18:27 AM (NOT Submittal)
Approve by Morman, Alaina 6/18/2021 5:04:59 PM (NOT Request Review- NCC190447)
• The task was assigned to Morman, Alaina. The due date is: June 23, 2021 5:00 PM
6/18/2021 9:18 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190447
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
Nby be blank (if not yet billed).
Information associated with this permit:
Project Name
Fire Flow Improvements and Water Main Replacement Phase 2
Address
Bolling Road, Roanoke Rapids, NC
County
Halifax
Latitude
37.4647
Longitude
-77.6531
Permittee Listed
Roanoke Rapids Sanitary District
Legally Responsible
R. Danieley Brown
Individual
NC Reference No.
NCG01-2019-0447
E&SC Plan ID
HALIF-2018-004
Original NOI
11642
Tracking No.
Date COC Issued
6/3/2019
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Cate populates only if COCwas already rescinded at time of submittal.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 6/17/2021
Inspection Approval
Project Close-out HALIF-2018-004_20210617_lnspRpt.pdf 36.32KB
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 Article; 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* R. Danieley Brown
Title * CEO
Organization* Roanoke Rapids Sanitary District
Date * 06/18/2021
Email for [e-mail]
Confirmation *
Contact Telephone* [phone] x 225
NOT Certification ncc190447_not _0001.pdf 696.13KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
OCd on Notification Errails
[e-mail]
CCd on Notification Errails
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]