NCC202311_Notice of Termination_20210823

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/23/2021 3:44:14 PM (NOT Submittal)
Approve by Morman, Alaina 8/24/2021 4:05:57 PM (NOT Request Review- NCC202311)
• The task was assigned to Morman, Alaina. The due date is: August 26, 2021 5:00 PM
8/23/2021 3:44 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC202311
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
fvby 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
Lumberton Memorial Park
Address
Elizabethtown Road, Lumberton, NC
County
Robeson
Latitude
34.6216
Longitude
-79.0093
Permittee Listed
City of Lumberton
Legally Responsible
Brandon Love
Individual
NC Reference No.
NCG01-2020-2311
E&SC Plan ID
ROBES-2019-012
Original NOI
26481
Tracking No.
Date COC Issued
6/9/2020
Prior Rescission
Cate populates only if OOC was already rescinded at tirre of submittal.
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 We information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Ibcurrentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 8/20/2021
Inspection Approval
Project Close-out ROBES-2020-012 INSP 8-20-2021.pdf 48.64KB
Approval Mist be FDFformat
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 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).
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
a0wok lig
Type Name* Brandon Love
Title * Deputy City Manager
Organization * City of Lumberton
Date * 08/23/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 910-671-3805
NOT Certification NCG01_NOT_Lumberton_Memorial_Park.pdf 706.24KB
Form Mist be FDF 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 Errails
Email [e-mail]