NCC210830_Notice of Termination_20210927

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/27/2021 9:23:13 AM (NOT Submittal)
Approve by Morman, Alaina 9/28/2021 10:25:16 AM (NOT Request Review- NCC210830)
• The task was assigned to Morman, Alaina. The due date is: September 30, 2021 5:00 PM
9/27/2021 9:23 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC210830
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
NDWRF & Acadia St Waterline Repl. & Fletcher's Chapel Rd Sanitary Sewer
Improv.
Address
Varies - easements near Fletcher's Chapel Rd, Acadia St, Camden Ave., Mist Lake
Dr., Durham, NC
County
Durham
Latitude
36.0223
Longitude
-78.8586
Permittee Listed
City of Durham
Legally Responsible
Donald Greeley
Individual
NC Reference No.
NCG01-2021-0830
E&SC Plan ID
DURHA-2020-013
Original NOI
43081
Tracking No.
Date COC Issued
2/11/2021
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Cate populates only if COCwas already rescinded at time of submittal.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 *
a Mistake or Invalid Coverage
Q Other
Additional Nbre information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 9/23/2021
Inspection Approval
Project Close-out DURHA-2020-013_20210923_lnspectionReport. pdf 197KB
Approval Mast be FDFformat
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
tVAIALP 6 r�Y
Type Name* Donald Greeley
Title * Director
Organization * City of Durham
Date * 09/27/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9195604381
NOT Certification NCG01-eNOT-Certification-Form-20210514-
Form DEMLR-SW - signed.pdf
Mast be FDF Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) [e-mail]
Original Permittee CCd on Wtification BTails
Email [e-mail]
284.74KB

Original Site Contact GCd on Wificaiton BTails
Email [e-mail]