NCC204036_Notice of Termination_20210806

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 8/6/2021 10:42:20 AM(NOT Submittal)
Approve by Morman,Alaina 8/11/2021 1:18:23 PM(NOT Request Review-NCC204036)
• The task was assigned to Morman,Alaina.The due date is:August 11,2021 5:00 PM
8/6/2021 10:42 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 NCC204036
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 Washington Interconnect
Address North Grimesland Bridge Road, Pactolus, NC
County Pitt
Latitude 35.5981
Longitude -77.1587
Permittee Listed Piedmont Natural Gas
Legally Responsible Dave Vena
Individual
NC Reference No. NCG01-2020-4036
E&SC Plan ID PITT-2020-012
Original NOI 31386
Tracking No.
Date COC Issued 9/15/2020
Prior Rescission Date populates only if OOC was already rescinded at tine of subaittal.
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 inforrration about the basis of this request,if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat

Project Close-out Information:
Final Close-out 6/28/2021
Inspection Approval
Project Close-out 20210628 cover letter&sedementation inspection
Approval 303.23KB
report PITT-2020-012 Wa....pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66(1) provides that:
Anyperson who knovvinglymakes 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 ofthe
Commission implementing this Article 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* Dave Vena
Title* Senior Project Manager
Organization* Piedmont Natural Gas
Date* 08/06/2021
Email for [e-mail]
Confirmation
Contact Telephone* 704 731-4496
NOT Certification NOT for Washington Interconnect Signed.pdf 665.34KB
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 57ails
Email [e-mail]

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