NCC201777_Notice of Termination_20210809

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 8/9/2021 11:04:56 AM(NOT Submittal)
Approve by Morman,Alaina 8/11/2021 2:42:29 PM(NOT Request Review-NCC201777)
• The task was assigned to Morman,Alaina.The due date is:August 12,2021 5:00 PM
8/9/2021 11:05 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 NCC201777
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 WRGC 540 AM New Tower
Address 928 Rufus Robinson Road,Sylva, NC
County Jackson
Latitude 35.3916
Longitude -83.2484
Permittee Listed Five Forty Broadcasting Company LLC
Legally Responsible Roy Burnette
Individual
NC Reference No. NCG01-2020-1777
E&SC Plan ID 19-117
Original NOI 24890
Tracking No.
Date COC Issued 5/1/2020
Prior Rescission Cate populates only if COC was already rescinded at time of submittal.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 2/3/2021
Inspection Approval
Project Close-out NOT ADDENDUMS01795520210809103610.pdf 348.5KB
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
Type Name* Roy Burnette
Title* Managing Member
Organization* Five Forty Broadcasting Company LLC
Date* 08/09/2021
Email for [e-mail]
Confirmation
Contact Telephone* 8285061329
NOT Certification NOT Certification01795620210809111416.pdf 437.94KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton 5,ails
Email [e-mail]

I I