NCC214626_Notice of Termination_20210914

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/14/2021 11:39:27 AM (NOT Submittal)
Approve by Morman, Alaina 9/19/2021 12:40:50 PM (NOT Request Review- NCC214626)
• The task was assigned to Morman, Alaina. The due date is: September 17, 2021 5:00 PM
9/14/2021 11:39 AM

1 �
NORTH CAROLINA
Enrlronmenral quallly
Certificate of NCC214626
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
McMullen Creek Tributary at Quail Hollow Rosemary and Sharon Hills Sewer
Rehab
Address
Rosemary Lane, Charlotte, NC
County
Mecklenburg
Latitude
35.1217
Longitude
-80.8425
Permittee Listed
City of Charlotte
Legally Responsible
Joseph C. Wilson
Individual
NC Reference No.
NCG01-2021-4626
E&SC Plan ID
MECKL-2021-021
Original NOI
62009
Tracking No.
Date COC Issued
8/18/2021
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submttal.
Date
Reason for Rescission/Termination Request:
Reason for F 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 Gbcurnentation if applicable.
Documentation NLstbeFOFforrrat

Project Close-out Information:
Final Close-out 9/2/2021
Inspection Approval
Project Close-out cwilson_9-9-2021_14-26-39_1.pdf 48.22KB
Approval Mist be FDFforrrat
Documentation
North Carolina General Statute 143-215.613 (i) 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 of the
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
,Taseph C- 10,ISO14
Type Name* Joseph C. Wilson
Title * Chief Engineer
Organization * City of Charlotte
Date * 09/14/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704-336-1083
NOT Certification eNOT Certification Form - SIGNED.pdf
Form Mast be FDF Format
Is this COCAlready Ensure this OOChas 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]
690.71 KB