NCC204486_Notice of Termination_20210907

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/7/2021 4:00:23 PM (NOT Submittal)
Approve by Morman, Alaina 9/8/2021 3:49:19 PM (NOT Request Review- NCC204486)
• The task was assigned to Morman, Alaina. The due date is: September 10, 2021 5:00 PM
9/7/2021 4:00 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC204486
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
Banner Branch Mitigation Project
Address
NC Highway 704 East, Lawsonville, NC
County
Stokes
Latitude
36.5254
Longitude
-80.2033
Permittee Listed
Water and Land Solutions
Legally Responsible
Kayne Van Stell
Individual
NC Reference No.
NCG01-2020-4486
E&SC Plan ID
STOKES-2021-005
Original NOI
32580
Tracking No.
Date COC Issued
10/7/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
F Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
O Mistake or Invalid Coverage
r Other
Additional Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 9/2/2021
Inspection Approval
Project Close-out 09-02-2021 Closure Inspection Report (STOKE -
Approval 248.11 KB
2021-005).pdf
Documentation
Mist be Ft7Fforrrat
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 deice 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
C; ` 4�r"�' "_A 5 �G
Type Name* Kayne Van Stell
Title * Vice President, Ecosystem Design Services
Organization * Water & Land Solutions, LLC
Date * 09/07/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9198188481
NOT Certification Banner Branch eNOT form.pdf
Form Mast be PDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email 0Cd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact OCd on Notificaiton 57ails
Email [e-mail]
79.07KB