NCC202685_Notice of Termination_20210625

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/25/2021 3:04:02 PM (NOT Submittal)
Approve by Morman, Alaina 6/25/2021 4:56:28 PM (NOT Request Review- NCC202685)
• The task was assigned to Morman, Alaina. The due date is: June 30, 2021 5:00 PM
6/25/2021 3:05 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202685
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
Nby be blank (if not yet billed).
Information associated
with this permit:
Project Name
Water Main Extension - Gold Hill Road / Washburn Road
Address
Gold Hill Road; Washburn Road, Madison, NC
County
Rockingham
Latitude
36.3133
Longitude
-79.9422
Permittee Listed
Rockingham County
Legally Responsible
Ronald Tate
Individual
NC Reference No.
NCG01-2020-2685
E&SC Plan ID
ROCKI-2020-017
Original NOI
27413
Tracking No.
Date COC Issued
6/25/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 MstbeRYforrrat

Project Close-out Information:
Final Close-out 6/23/2021
Inspection Approval
Project Close-out Inspection Report 06-23-2021 Gold Hill Extension
Approval 90.36KB
Closeout Report.pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording 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 notto 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 * Ronald E. Tate
Title * Director of Engineering & Public Utilities
Organization* Rockingham County
Date * 06/25/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 3363428104
NOT Certification NCG01 Notice of Termination Signed.pdf
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email rtate@co. rocking ham. nc. us
392.37KB