NCC203301_Notice of Termination_20210929

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/29/2021 10:09:23 AM (NOT Submittal)
Approve by Morman, Alaina 10/4/2021 8:36:51 PM (NOT Request Review- NCC203301)
• The task was assigned to Morman, Alaina. The due date is: October 4, 2021 5:00 PM
9/29/2021 10:09 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC203301
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
fvby be blank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Review step) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
RTAMS TLZ Repair - Erosion Repair Areas at TLZ Lark
Address
Highway 172, Camp Lejeune, NC
County
Onslow
Latitude
34.6720
Longitude
-77.2400
Permittee Listed
MCB Camp Lejeune
Legally Responsible
Neal Paul
Individual
NC Reference No.
NCG01-2020-3301
E&SC Plan ID
ONSLO-2021-001
Original NOI
29230
Tracking No.
Date COC Issued
8/4/2020
Prior Rescission
Cate populates only if OOC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:

Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a newCOC)
Coverage * r Mistake or Invalid Coverage
f Other
Additional We information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Ibcurrentation if applicable.
Documentation Mist bePDFformat
Project Close-out Information:
Final Close-out 9/15/2021
Inspection Approval
Project Close-out RTAMS TLZ Repairs at TLZ Lark - 9.15.21 -
Approval 256.23KB
close.pdf
Documentation
Mist be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowinglyrenders
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 notto exceed ten thousand
dollars ($10,000).
I7 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
T"ti�t1ww
Type Name* Talia Prendergast
Title * PWD Civil Engineer
Organization * MCB Camp Lejeune
Date * 09/29/2021
Email for [e-mail]
Confirmation *
Contact Telephone * [phone] ext. 3242
NOT Certification 19-0166_TLZLark_NOTCertForm 08.23.21.pdf 68.18KB
Form Mist be PDF Forrrat

Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email 0Cd on Notification Errails
(Optional) heather. [e-mail]
Original Permittee 0Cd onNiotificationErrails
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]