NCC201350_Notice of Termination_20210721

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 7/21/2021 3:14:23 PM(NOT Submittal)
Approve by Morman,Alaina 7/23/2021 3:40:59 PM(NOT Request Review-NCC201350)
• The task was assigned to Morman,Alaina.The due date is:July 26,2021 5:00 PM 7/21/2021 3:14 PM

" 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 NCC201350
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
fvby be blank(if not yet billed).
Information associated with this permit:
Project Name PING Line 243 Retrofit Launcher
Address Tuscarora Rhems Road, New Bern, NC
County Craven
Latitude 35.0000
Longitude -77.0000
Permittee Listed Piedmont Natural Gas inc.
Legally Responsible Sanu Odugbesan
Individual
NC Reference No. NCG01-2020-1350
E&SC Plan ID Crane-2020-026
Original NOI 23908
Tracking No.
Date COC Issued 4/3/2020
Prior Rescission Cate populates only if COC was already rescinded at tin-e of subrrittal.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* r Mistake or Invalid Coverage
r Other
Addional We information about the basis of this request,if needed.
Explanation Project complete, please see attached Final
Inspection performed July 9,2021 and
inspection report dated July 12,2021.

Supporting Upload Supporting Documentation if applicable.
Documentation Wst be FM format
Project Close-out Information:
Final Close-out 7/12/2021
Inspection Approval
Project Close-out 210709 LAUNCHER DUKE CRAVE-2020-026.pdf 32.3KB
Approval Mast be FDFformat
Documentation
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 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 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 Article 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
AOlc�Y# i0olk9'
Type Name* Adam Pollak
Title* Project Manager
Organization* Piedmont Natural Gas
Date* 07/21/2021
Email for [e-mail]
Confirmation
Contact Telephone* 9524562648
NOT Certification Line 243 Launcher NOT NCC201350.pdf 40.57KB
Form Mast be FDF Format
Is this COCAlready Ensure this OOC has not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) [e-mail]
Original Permittee 0Cd on Notification BTails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]