NCC205045_Notice of Termination_20210708

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/8/2021 4:26:34 PM (NOT Submittal)
Approve by Morman, Alaina 7/9/2021 11:04:30 AM (NOT Request Review- NCC205045)
• The task was assigned to Morman, Alaina. The due date is: July 13, 2021 5:00 PM 7/8/2021 4:27 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC205045
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
Fairfax Meter Lan/Trans-Mobile Transformer Storage Shelter
Address
2200 Fairfax Road, Greensboro, NC
County
Guilford
Latitude
36.0385
Longitude
-79.8748
Permittee Listed
Duke Energy Progress
Legally Responsible
Carol Fadden
Individual
NC Reference No.
NCG01-2020-5045
E&SC Plan ID
GUILF-2020-023
Original NOI
35095
Tracking No.
Date COC Issued
11/10/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 6/30/2021
Inspection Approval
Project Close-out 6-30-2021 Inspection Report GUILF-2020-023
Approval Fairfax Meter LabTrans-Mobile Transformer Storage 136.36KB
Documentation
Shelter_.pdf
Mist 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 A tide; 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* Eric J Rouse
Title * Director, Land Services
Organization* Duke Energy
Date * 07/08/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 919-481-6132
NOT Certification Fairfax NOT. pdf
Form Mist be FDF Forrrat
Is this COC Already Ensure this COChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Bmils
(Optional) [e-mail]
Original Permittee CCd on Wtification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]
730.41 KB