NCC200761_Notice of Termination_20210921

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/21/2021 11:45:44 AM (NOT Submittal)
Approve by Morman, Alaina 9/27/2021 4:48:50 PM (NOT Request Review- NCC200761)
• The task was assigned to Morman, Alaina. The due date is: September 24, 2021 5:00 PM
9/21 /2021 11:45 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200761
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
South Fork Interceptor No.3 Outfall Replacement
Address
Follansbee Rd, Winston-Salem, NC
County
Forsyth
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Winston Salem Forsyth County Utilities
Legally Responsible
Courtney Driver
Individual
NC Reference No.
NCG01-2020-0761
E&SC Plan ID
FORSY-2019-004
Original NOI
22168
Tracking No.
Date COC Issued
2/26/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 7/27/2021
Inspection Approval
Project Close-out 07-27-2021 Closure Inspection Report (FORSY-
Approval 246.3KB
2019-004).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
Type Name* Courtney Driver
Title * Utilities Director
Organization* Winston Salem Forsyth County Utilities
Date * 09/21 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-747-7315
NOT Certification NCG01 Notice of Termination Form.pdf 44.91 KB
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Erails
[e-mail]
Original Site Contact OCd on Notificaiton BTails
Email [e-mail]