NCC202601_Notice of Termination_20210908

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/8/2021 12:07:07 PM (NOT Submittal)
Approve by Morman, Alaina 9/14/2021 10:42:12 AM (NOT Request Review- NCC202601)
• The task was assigned to Morman, Alaina. The due date is: September 13, 2021 5:00 PM
9/8/2021 12:07 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202601
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
R-4707 Duke Utilities Relocation
Address
US 29 and Reedy Fork Parkway, Greensboro, NC
County
Guilford
Latitude
36.1700
Longitude
-79.7155
Permittee Listed
Duke Energy
Legally Responsible
Justin Ambrose
Individual
NC Reference No.
NCG01-2020-2601
E&SC Plan ID
GUILF-2020-040
Original NOI
27145
Tracking No.
Date COC Issued
6/19/2020
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Cate populates only if COCwas already rescinded at time of submittal.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
Additional IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation MstbeRYforrrat

Project Close-out Information:
Final Close-out 9/2/2021
Inspection Approval
Project Close-out 4707 Summit Ave Closeout Report 9-2-2021.pdf 248.44KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto 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* Justin Ambrose
Title * Project Manager
Organization* Duke Energy
Date * 09/08/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 2527020294
NOT Certification 4707 Summit Ave NOT Cert Form.pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Notification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
489.76KB