NCC202832_Notice of Termination_20211005

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/5/2021 10:41:17 AM (NOT Submittal)
Approve by Morman, Alaina 10/11/2021 3:20:36 PM (NOT Request Review- NCC202832)
• The task was assigned to Morman, Alaina. The due date is: October 8, 2021 5:00 PM
10/5/2021 10:41 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202832
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
PAID
Nt3y be blank (if not yet billed).
Information associated
with this permit:
Project Name
Wilkes County Airport - Samaritan's Purse Hangar Building
Address
640 Wood Wallace Dr., N. Wilkesboro, NC
County
Wilkes
Latitude
36.2270
Longitude
-81.1030
Permittee Listed
Samaritan's Purse
Legally Responsible
Greg Yancey
Individual
NC Reference No.
NCG01-2020-2832
E&SC Plan ID
WILKES-2020-012
Original NOI
27664
Tracking No.
Date COC Issued
7/6/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 beRFforrrat

Project Close-out Information:
Final Close-out 9/24/2021
Inspection Approval
Project Close-out #1 WILKE-2020-012, Wilkes County Airport -
Approval Samaritan's Purse Hangar Building, 9-24-2021 37.98KB
Documentation
closure report.pdf
Wst be FDFforrrat
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 Artide or a rule implementing this Artide; 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 Artide 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
Type Name* Ronald E. Wilcox
Title * Chief Operating Officer
Organization* Samaritan's Purse
Date * 10/05/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 8282781511
NOT Certification NOT Certification Form - Signed 10-05-2021.pdf 665.26KB
Form Mist be FDF Format
Is this COC Already Ensure this COChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
0Cd on Notification B7ails
[e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]