NCC201163_Notice of Termination_20220304

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/4/2022 7:00:32 AM (NOT Submittal)
Approve by Morman, Alaina 3/7/2022 4:19:09 PM (NOT Request Review - NCC201163)
• The task was assigned to Morman, Alaina. The due date is: March 9, 2022 5:00 PM 3/4/2022 7:00 AM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC201163
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 OPEN
Status May be blank (if not yet billed).
Information associated with this permit:
Project Name 2019 Water System Improvements, CN 147-Interconnects
Address Old Hwy 117, Cricket Ridge, Country Club, Old Mt. Olive, Genoa, Everett, Dudley,
NC
County Wayne
Latitude 35.2421
Longitude-78.0691
Permittee Listed Southeastern Wayne Sanitary District
Legally Responsible Phil Shivar
Individual
NC Reference No. NCG01-2020-1163
E&SC Plan ID Wayne-2019-034
Original NOI Tracking 23334
No.
Date COC Issued 3/23/2020
Prior Rescission Date Date populates only if COC was already rescinded at time of submittal.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 1/11/2022
Inspection Approval
Project Close-out 20220111 sed insp report WAYNE-2019-034 SE
Approval Wayne Sant. Dis.pdf
Documentation
Must be PDF format
North Carolina General Statute 143-215.613 (i) provides that:
166.79KB
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
�cG�7rFcU�
Type Name* Phil Shivar
Title * Chairman
Organization * Southeastern Wayne Sanitary District
Date* 03/04/2022
Email for [e-mail]
Confirmation *
Contact Telephone* 919-736-7630
NOT Certification SEWSD CN 147-Interconnects NCG01 NOT
Form 1.23MB
Form.pdf
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]