NCC203485_Notice of Termination_20210708

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/8/2021 11:47:16 AM (NOT Submittal)
Approve by Morman, Alaina 7/9/2021 10:01:23 AM (NOT Request Review- NCC203485)
• The task was assigned to Morman, Alaina. The due date is: July 13, 2021 5:00 PM 7/8/2021 11:47 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC203485
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Line 182 Removal Wharton -Washington
Address
Multiple, Washington, NC
County
Beaufort
Latitude
36.0000
Longitude
-77.0000
Permittee Listed
Virginia Electric and Power Company d/b/a Dominion Energy North
Carolina
Legally Responsible
Kevin Fields
Individual
NC Reference No.
NCG01-2020-3485
E&SC Plan ID
Beauf-2021-001
Original NOI
29770
Tracking No.
Date COC Issued
8/13/2020
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submttal.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a new COC)
Coverage * r Mistake or Invalid Coverage
r Other
Add Tonal IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Gbcurnentation if applicable.
Documentation NLstbeFOFforrrat

Project Close-out Information:
Final Close-out 7/6/2021
Inspection Approval
Project Close-out 210706 Line 182 Removal Wharton Washington
Approval 20.84KB
BEAUF-2021-001 (002).pdf
Documentation
Wst be FDFforrrat
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* Donald Hoover
Title * Manager, Electric Transmission and Substation Construction
Organization * Virginia Electric and Power Company
Date * 07/08/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 8047731046
NOT Certification Notice of Termination (NOT) Certification Form.pdf 669KB
Form Mist be FDF Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional) [e-mail]
Original Permittee CCdonWificationErails
Email [e-mail]
Original Site Contact CCd on Notificaiton Ermils
Email [e-mail]