NCC201838_Notice of Termination_20210719

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 7/19/2021 11:41:26 AM(NOT Submittal)
Approve by Morman,Alaina 7/20/2021 9:17:27 AM(NOT Request Review-NCC201838)
• The task was assigned to Morman,Alaina.The due date is:July 22,2021 5:00 PM
7/19/2021 11:41 AM

" RequestNOT • Construction Stormwater
1 i
�a•aThis formto request Notice of • • for •co\erage under •
NORTH CAROLINA General - for • i i• Activities Qr�arrry
Certificate of NCC201838
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
May be blank(if not yet billed).
Information associated with this permit:
Project Name Scarborough Mitigation Project
Address Casey Mill Road, Dudley, NC
County Wayne
Latitude 35.0000
Longitude -78.0000
Permittee Listed Water and Land Solutions
Legally Responsible Kayne VanStell
Individual
NC Reference No. NCG01-2020-1838
E&SC Plan ID Wayne-2020-015
Original NOI 25116
Tracking No.
Date COC Issued 5/11/2020
Prior Rescission Cate populates only if COC was already rescinded at time of submittal.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 7/15/2021
Inspection Approval
Project Close-out 20210713 sed insp report WAYNE-2020-015
Approval 177.15KB
Scarborough Mit.pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66(1) provides that:
Any person who knowingly makes anyfalse statement,representation,or certification in any application,record,report,plan,or other
document filed 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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which may include 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* Kayne Van Stell
Title* Vice President, Ecosystem Design Services
Organization* Water&Land Solutions
Date* 07/19/2021
Email for [e-mail]
Confirmation
Contact Telephone* 9198188481
NOT Certification Scarborough NCG01 eNOT Form signed.pdf 61.79KB
Form Mast be PDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]

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