NCC192774_Notice of Termination_20230105

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/5/2023 4:09:13 PM (NOT Submittal)
Approve by Clark, Paul B 1/9/2023 5:23:55 PM (NOT Request Review - NCC192774)
F project closeout date = 8/11/2021, invoice due date = 12/1/2022. waive fee. COC to be rescinded.
• The task was assigned to Clark, Paul B by round robin distribution 1/5/2023 4:09 PM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: January 10, 2023 5:00
PM 1/5/2023 4:09 PM

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(COC) will be rescinded.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 NCC192774
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status
PAID
May be blank if N/A
2023 Annual Fee Status
May be blank if N/A
Information associated with this permit
2021 Annual Fee Status 2022 Annual Fee Status
PAID WAIVED
May be blank if N/A May be blank if N/A
Project Name Cornwell Health New Parking Lot
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 6114 US Highway 301, Four Oaks, NC
County Johnston
Latitude 35.4465
Longitude-78.4238
Permittee Listed Tri-County Community Health Council, Inc. DBA Commwell Health
Legally Responsible Pamela Tripp
Individual
NC Reference No. NCG01-2019-2774
E&SC Plan ID JOHNS-2020-008
Original NOI Tracking 18441
No.
Date COC Issued 11/21/2019
Prior Rescission Date Date populates only if COC was already rescinded at time of submittal.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:
Erosion Control Plan 8/11/2021
Close-out Date
Erosion Control Plan Close Out Inspection Report - Cornwell Health New
Close-out 29.35KB
Parking Lot.pdf
Documentation
Must be PDF format
North Carolina General Statute 143-215.613 (1) 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
Type Name* Pamela Tripp
Title* CEO
Organization * Tri-County Community Health Council, Inc. DBA Commwell Health
Date * 01 /05/2023
Email for [e-mail]
Confirmation*
Contact Telephone* 877-935-5255
NOT Certification NOT Form - Cornwell Health New Parking Lot -
Form 47.23KB
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]