NCC193166_Notice of Termination_20220118

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/18/2022 11:54:01 AM (NOT Submittal)
Approve by Morman, Alaina 1/19/2022 3:01:49 PM (NOT Request Review - NCC193166)
• The task was assigned to Morman, Alaina. The due date is: January 21, 2022 5:00 PM
1/18/2022 11:54 AM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC193166
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status PAID
2021 Annual Fee Status PAST DUE
May be blank (if not yet billed).
2022 Annual Fee May be blank (if not yet billed).
Status
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
Sorensen
Address
7636 Ladora Drive, Willow Spring, NC
County
Wake
Latitude
35.5812
Longitude
-78.7029
Permittee Listed
Land Owner
Legally Responsible
Michael Sorensen
Individual
NC Reference No.
NCG25-2019-3166
E&SC Plan ID
SEC-023662-2019
Original NOI Tracking
19451
No.
Date COC Issued
12/16/2019
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Date populates only if COC was already rescinded at time of submittal.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 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 1/7/2022
Inspection Approval
Project Close-out SEC-023662-2019_Certificate of Completion_ 1-7-
Approval 22.pdf 142.25KB
Documentation
Must be PDF format
North Carolina General Statute 143-215.613 (i) 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
��r-lr�z�e'C1r a�ot�flra�r
Type Name* Michael Keith Sorensen
Title* owner
Organization* Sorensen Contracting Corp
Date * 01 /18/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 919-795-5975
NOT Certification NOT Cert Form 7636 Ladora Dr.pdf 720.92KB
Form Must be PDF Format
Is this COC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emails
(Optional)

Original Permittee cc'd on Notification Emails
Email [e-mail]
Original Site Contact cc'd on Notificaiton Emails
Email [e-mail]