NCC204041_Notice of Termination_20210929

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/29/2021 8:38:12 AM (NOT Submittal)
Approve by Morman, Alaina 10/4/2021 8:28:38 PM (NOT Request Review- NCC204041)
• The task was assigned to Morman, Alaina. The due date is: October 4, 2021 5:00 PM
9/29/2021 8:38 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC204041
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
Nby be blank (if not yet billed).
Information associated with this permit:
Project Name
Evans
Address
41 Creek Run rd, Candler, NC
County
Buncombe
Latitude
36.0000
Longitude
-83.0000
Permittee Listed
Micheal and Kimberly Evans
Legally Responsible
Kimberly Evans
Individual
NC Reference No.
NCG01-2020-4041
E&SC Plan ID
ER02020-00036
Original NOI
31412
Tracking No.
Date COC Issued
9/17/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 9/17/2021
Inspection Approval
Project Close-out IMG_3101 copy.pdf
Approval IMG 3100 co df
_ PY•P
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
389.48KB
400.29KB
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
` fir?: � rli2s�ct
Type Name* Kimberly Evans
Title * Mrs
Organization* Na
Date * 09/29/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 8287134032
NOT Certification IMG_3107.jpg.pdf 2.05MB
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Erails
CCd on Notification Bmils
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]