NCC202457_Notice of Termination_20210726

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/26/2021 11:47:58 AM (NOT Submittal)
Approve by Morman, Alaina 7/27/2021 1:59:04 PM (NOT Request Review- NCC202457)
• The task was assigned to Morman, Alaina. The due date is: July 29, 2021 5:00 PM
7/26/2021 11:48 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC202457
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
Nby be blank (iF not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Review step) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Whittier Creek Restoration
Address
Rock Hill Church Road, Eldora, NC
County
Surry
Latitude
36.3779
Longitude
-80.5999
Permittee Listed
Michael Baker International
Legally Responsible
Dwain Hathaway
Individual
NC Reference No.
NCG01-2020-2457
E&SC Plan ID
SURRY-2020-026
Original NOI
26824
Tracking No.
Date COC Issued
6/11/2020
Prior Rescission
Cate populates only ff OOCwas already rescinded at tirre of subaittal.
Date
Reason for Rescission/Termination Request:

Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a newCOC)
Coverage * r Mistake or Invalid Coverage
f Other
Add ional Mxe information about the basis of this request, if needed.
Explanation This was a stream restoration project that
was completed in early June 2021. The
closeout inspection was completed by Tyler
Pearson on 7/19/21.
Supporting Upload Supporting DDcurrentation if applicable.
Documentation Mist bePDFformat
Project Close-out Information:
Final Close-out 7/19/2021
Inspection Approval
Project Close-out 07-14-2021 Closure Inspection Report (SURRY-
Approval 245.31 KB
2021-026).pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (1) 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 Atcle; 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 ofthe
Commission implementing this Atcle shall be guiltyofa Class 2 misdemeanor which mayinclude 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* Dwain Hathaway
Title * Office Executive
Organization* Michael Baker International
Date * 07/26/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 919-481-5702

NOT Certification NCG01-eNOT-Certification-Form-20210514-
Form DEMLR-SW forDH SIGNED.pdf
Mast be PDF Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Bmils
(Optional) [e-mail]
Original Permittee 0Cd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Emils
Email [e-mail]
337.1 KB