NCC213629_Notice of Termination_20231013

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 10/13/2023 11:51:48 AM (NOT Submittal)
Approve by Kieu Tran 10/17/2023 3:53:24 PM(NOT Request Review-NCC213629)
• The task was assigned to DEMLR NCG01 NOT Review Team.The due date is: October 18,2023 5:00
PM 10/13/2023 11:51:49 AM
• The task was assigned to Kieu Tran by round robin distribution 10/13/2023 11:51:49 AM

Q� Notice of Termination (NOT) Request - NPDE,�tz_
Stormwater Permit for . •
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 NCG010000(or NCG250000). If approved,the Certificate of Coverage
(COC)will be rescinded.
Certificate of NCC213629
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 May be blank if N/A PAID
May be blank if N/A
2023 Annual Fee Status
PAID
May be blank if N/A
Information associated with this permit:
Project Name Hickory High School-Turf Soccer Field
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 1234 3rd Street NE, Hickory, NC
County Catawba
Latitude 35.7490
Longitude -81.3320
Permittee Listed GeoSurfaces Southeast, Inc.
Legally Responsible Lance Rosenberger
Individual
NC Reference No. NCG01-2021-3629
E&SC Plan ID CATAW-2021-018
Original NOI Tracking 56514
No.
Date COC Issued 6/17/2021
Prior Rescission Date Date populates only if COC was already rescinded at time of submittal.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 3/2/2022
Close-out Date
Erosion Control Plan closeout Inspection Hickory High School.pdf 29.28KB
Close-out Must be PDF format
Documentation
North Carolina General Statute 143-215.6B(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* Lance Rosenberger
Title* SVP of Construction Services
Organization* GeoSurfaces SE,Inc.
Date* 10/13/2023
Email for [e-mail]
Confirmation*
Contact Telephone* 7046603000
NOT Certification Hickory High School NOT.pdf 828.49KB
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)
Original Permittee CC'd on Notification Emails
Email [e-mail]

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