NCC202088_Notice of Termination_20210728

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/28/2021 9:30:23 AM (NOT Submittal)
Approve by Morman, Alaina 7/29/2021 1:39:00 PM (NOT Request Review- NCC202088)
• The task was assigned to Morman, Alaina. The due date is: August 2, 2021 5:00 PM
7/28/2021 9:30 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC202088
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
Nby be blank (if not yet billed).
Information associated with this permit:
Project Name
Fayetteville Metropolitan Housing Authority
Address
Wiley Street, Fayetteville, NC
County
Cumberland
Latitude
35.0690
Longitude
-78.8800
Permittee Listed
Fayetteville Metropolitan Housing Authority
Legally Responsible
Dawn Weeks
Individual
NC Reference No.
NCG01-2020-2088
E&SC Plan ID
CUMBE-2020-098
Original NOI
25653
Tracking No.
Date COC Issued
6/22/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.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 7/23/2021
Inspection Approval
Project Close-out CUMBE-2020-098 INSP20210723 CO.pdf 93.81KB
Approval Mast be FDFforrrat
Documentation
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 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 of the
Commission implementing this Artcle 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
ZW P1016e
Type Name* Dawn Weeks
Title * Executive Director
Organization* Fayetteville Metropolitan Housing Authority
Date * 07/28/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 910-916-6172
NOT Certification Notice of Termination Certification Form.pdf 427.38KB
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Erails
CCd on Notification Bmils
[e-mail]
Original Site Contact CCd on Notificaiton 5,ails
Email [e-mail]