NCC201165_Notice of Termination_20211012

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/12/2021 11:10:26 AM (NOT Submittal)
Approve by Morman, Alaina 10/12/2021 2:01:30 PM (NOT Request Review- NCC201165)
• The task was assigned to Morman, Alaina. The due date is: October 15, 2021 5:00 PM
10/12/2021 11:10 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201165
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
West Mecklenburg High School Gym Addition
Address
7400 Tuckaseegee Road, Charlotte, NC
County
Mecklenburg
Latitude
35.2490
Longitude
-80.9520
Permittee Listed
Charlotte Mecklenburg Board of Education
Legally Responsible
Gary Adams
Individual
NC Reference No.
NCG01-2020-1165
E&SC Plan ID
MECCKL-2020-043
Original NOI
23320
Tracking No.
Date COC Issued
3/30/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 8/24/2021
Inspection Approval
Project Close-out 08.24.21 NCDEQ Inspection Report.pdf 51.47KB
Approval Mast be FDFforrrat
Documentation
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 under this 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 of the
Commission implementing this Artcle 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* Gary S Adams
Title * Director of Architecture
Organization* Charlotte Mecklenburg Schools
Date * 10/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704.201.9938
NOT Certification NCGO1 Executed.pdf
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Notification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
40.57KB