NCC202802_Notice of Termination_20210913

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/13/2021 5:03:44 PM (NOT Submittal)
Approve by Morman, Alaina 9/19/2021 12:29:41 PM (NOT Request Review- NCC202802)
• The task was assigned to Morman, Alaina. The due date is: September 16, 2021 5:00 PM
9/13/2021 5:03 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202802
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
PAID
Nt3y be blank (if not yet billed).
Information associated
with this permit:
Project Name
Copart Phase 2 Cat. Lot
Address
Hwy 72, Lumberton, NC
County
Robeson
Latitude
34.6582
Longitude
-79.0866
Permittee Listed
Valfair
Legally Responsible
Gary Brown
Individual
NC Reference No.
NCG01-2020-2802
E&SC Plan ID
ROBES-2020-026
Original NOI
27688
Tracking No.
Date COC Issued
7/6/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 Mist beRYforrrat

Project Close-out Information:
Final Close-out 9/13/2021
Inspection Approval
Project Close-out ROBES-2020-026 Close Out Inspection 9-13-
Approval 48.58KB
2021.pdf
Documentation
Mast be FDFforrrat
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
��jr�v�r CG
Type Name* Bryson Hall
Title * Project Manager
Organization* Valfair Construction
Date * 09/13/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 4696426021
NOT Certification 3429236798-49658-16652-187-20.pdf
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
97.96KB