NCC200195_Notice of Termination_20211019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/19/2021 9:09:18 AM (NOT Submittal)
Approve by Morman, Alaina 10/19/2021 1:30:25 PM (NOT Request Review - NCC200195)
• The task was assigned to Morman, Alaina. The due date is: October 22, 2021 5:00 PM
10/19/2021 9:09 AM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC200195
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status
2021 Annual Fee Status PAID
May be blank (if not yet billed).
Information associated with this permit:
Project Name
Union County - CDBG Highway 218 Water Main Extension
Address
Highway 218, New Salem, NC
County
Union
Latitude
35.1275
Longitude
-80.3619
Permittee Listed
Union County Public Works
Legally Responsible
John Shutak
Individual
NC Reference No.
NCG01-2020-0195
E&SC Plan ID
UNION-2020-049
Original NOI Tracking
20770
No.
Date COC Issued
2/28/2020
Prior Rescission Date
Date populates only if COC was already rescinded at time of submittal.
Reason for Rescission/Termination Request:
Reason for Project Closed -Out
Termination of Sale (Another Owner/Operator obtained a new COC)
Coverage* Mistake or Invalid Coverage
Other
Additional More information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation Must be PDF format
Project Close-out Information:

Final Close-out 10/13/2021
Inspection Approval
Project Close-out UNION-2020-049_Hwy 218 Water
Approval 116.55KB
Main_10.13.2021.pdf
Documentation
Must be PDF format
North Carolina General Statute 143-215.613 (1) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document
filed 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 device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
9Q FvJ Wlr
Type Name* Thomas Mann
Title* CIP Program Manager
Organization * Union County Water
Date * 10/19/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704.292.2560
NOT Certification NCG01-eNOT-Certification-Form-20210514-DEMLR-
Form 681.63KB
SW_Signed.pdf
Must be PDF Format
Is this CDC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emails
(Optional) [e-mail]
Original Permittee CC'd on Notification Emails
Email [e-mail]
Original Site Contact CC'd on Notificaiton Emails
Email [e-mail]