NCC203999_Notice of Termination_20220923

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/23/2022 11:22:57 AM (NOT Submittal)
Approve by Clark, Paul B 9/28/2022 4:14:46 PM (NOT Request Review - NCC203999)
• The task was assigned to Clark, Paul B by round robin distribution 9/23/2022 11:23 AM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: September 28, 2022 5:00
PM 9/23/2022 11:23 AM

Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCGO10000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC203999
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
May be blank if N/A PAID OPEN
May be blank if N/A May be blank if N/A
This permittee has an OPEN fee. If this NOT request is acceptable, you will have the option to waive that fee, but that is
only available AFTER the Notice of Termination (NOT) has been approved (when the permit status becomes INACTIVE).
If it is appropriate to waive the OPEN fee, it may help to assign that annual fee task to yourself immediately following this
approval so you remember to resolve the outstanding fee.
Information associated with this permit:
Project Name Atlantic Casualty Insurance Co./Auto-Owners Life Insurance Co. - Phase 1
Lots Covered by this This information is especially helpful when more lots were added with Modifications since the original permit
Permit COC (if issuance.
applicable) No longer visible on the initial form (data not captured from initial application)
Address 400 Commerce Court (Lot 4, Industrial Park), Goldsboro, NC
County Wayne
Latitude 35.3724
Longitude-77.9243
Permittee Listed Auto -Owners Insurance Company
Legally Responsible Lisa M. Ayotte
Individual
NC Reference No. NCG01-2020-3999
E&SC Plan ID Wayne-2021-003
Original NOI Tracking 31213
No.
Date COC Issued 9/18/2020
Prior Rescission Date Date populates only if COC was already rescinded at time of submittal.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:
Erosion Control Plan 9/9/2022
Close-out Date
Erosion Control Plan 20220908 sed insp report WAYNE-2021-003 Atlantic
Close-out 165.74KB
Insurance.pdf
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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
Type Name* Lisa M. Ayotte
Title* Vice -President -Operational Services & Real Estate
Organization * AutoOwners Insurance
Date * 09/23/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 5173238720
NOT Certification Auto -Owners - Notice of Termination Form -
Form 236.24KB
SIGNED.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) [e-mail]
Original Permittee CC'd on Notification Emails
Email [e-mail]
Original Site Contact CC'd on Notificaiton Emails
Email [e-mail]