NCC200726_Notice of Termination_20220208

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/8/2022 1:34:55 PM (NOT Submittal)
Approve by EADS\amorman1 2/11/2022 5:14:29 PM (NOT Request Review - NCC200726)
• The task was assigned to Morman, Alaina. The due date is: February 11, 2022 5:00 PM
2/8/2022 1:34 PM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC200726
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).
2022 Annual Fee PAID
Status May be blank (if not yet billed).
Information associated with this permit:
Project Name
Old 109 Water Mains
Address
E Holly Grove Road, Thomasville, NC
County
Davidson
Latitude
35.8407
Longitude
-80.0918
Permittee Listed
Davidson Water, Inc.
Legally Responsible
Robert Walters
Individual
NC Reference No.
NCG01-2020-0726
E&SC Plan ID
DAVID-2020-024
Original NOI Tracking
22257
No.
Date COC Issued
2/25/2020
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Date populates only if COC was already rescinded at time of submittal.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 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 11/30/2021
Inspection Approval
Project Close-out Final water Mains Inspection Report 11-30-21
Approval (DAVID-2020-024).pdf
Documentation
Must be PDF format
North Carolina General Statute 143-215.613 (i) provides that:
130.19KB
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
Type Name* Robert Walters
Title * Vice President Construction & Engineering
Organization* Davidson Water Inc
Date* 02/08/2022
Email for [e-mail]
Confirmation *
Contact Telephone* 3367315526
NOT Certification Davidson Water NOT Cert. Water Mains pdf.pdf 68.25KB
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) [e-mail]
Original Permittee CC'd on Notification Emails
Email [e-mail]

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