NCC200769_Notice of Termination_20220329

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/29/2022 8:09:55 AM (NOT Submittal)
Approve by Morman, Alaina 3/31/2022 8:46:04 AM (NOT Request Review - NCC200769)
• The task was assigned to Morman, Alaina. The due date is: April 1, 2022 5:00 PM 3/29/2022 8:10 AM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC200769
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
Riverdale Sanitary Sewer Extension & Improvements
Address
Riverdale Drive, Jamestown, NC
County
Guilford
Latitude
35.9445
Longitude
-79.9120
Permittee Listed
City of High Point
Legally Responsible
Terry Houk
Individual
NC Reference No.
NCG01-2020-0769
E&SC Plan ID
GUILF-2020-024
Original NOI Tracking
22346
No.
Date COC Issued
2/27/2020
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Date populates only if COC was already rescinded at time of submittal.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 Legally responsible individual has retired.
Robby Stone is the current legally
responsible individual acting as Interim Public
Services Director
Supporting Upload Supporting Documentation if applicable.
Documentation Must be PDF format
Project Close-out Information:
Final Close-out 3/22/2022
Inspection Approval
Project Close-out 3-22-2022 Inspection Report GUILF-2020-024
Approval Riverdale Sewer Extension and Improvements_.pdf
Documentation
Sediment Inspection Report.pdf
Must be PDF format
North Carolina General Statute 143-215.613 (i) provides that:
92.88KB
282.32KB
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* Robby Stone
Title* Interim Public Services Director
Organization* City of High Point
Date * 03/29/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 336 883 3217
NOT Certification Erosion Close Out - NOT.pdf 385.81 KB
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]