NCC190586_Notice of Termination for DUPLICATE COC_20190614

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/14/2019 1:38:15 PM (NOT Submittal)
Approve by Georgoulias, Bethany 6/14/2019 3:17:59 PM (NOT Request Review- NCC190586)
• The task was assigned to Georgoulias, Bethany by round robin distribution 6/14/2019 1:38 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: June 19, 2019 5:00 PM
6/14/2019 1:38 PM

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NORTH CAROLINA
Ernvlronmental Qualily
Certificate of
NCC190586
Coverage (COC)
Enter the Certificate of Coverage Nurrbeer
No. *
Information associated
with this permit:
Project Name
Project Heidi
Address
Brewer Road and Highway 96, Four Oaks, NC
County
Johnston
Latitude
35.4430
Longitude
-78.4075
Permittee Listed
TKC CCLXXV, LLC
Legally Responsible
Alan Lewis
Individual
NC Reference No.
NCG01-2019-0586
E&SC Plan ID
JOHNS-2019-027
Original NOI
12048
Tracking No.
Date COC Issued
6/11/2019
Prior Rescission
This field will populate only if 0OChas already been rescinded.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Addional Ivbre infornation about the basis of this request, if needed.
Explanation Duplicate - Project was also approved under
COC NCC190587 and will maintain coverage
under that permit.
Supporting 1pload Supporting Docunentation if applicable.
Documentation WstbeFDFfornat
Project Close-out Information:

Final Close-out
Inspection Approval
Project Close-out Mast beFDFforrrat
Approval
Documentation
North Carolina General Statute 143-215.613 (1) provides that:
Any person who knowingly makes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained underthis Article or a rule implementing this Article; orwho knowinglymakes 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 deiceor method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyof a Class 2 misdemeanor which mayinclude a fine not to e)ceed ten thousand
dollars ($10,000).
rJ 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
Am o �
Type Name * ken beuley
Title * CFO
Organization* The Keith Corp
Date * 06/14/2019
Email for [e-mail]
Confirmation *
Contact Telephone* 704.319.8134
NOT Certification Construction Stormwater_ Notice of Intent (NOI).pdf 73.56KB
Form noi.pdf 68.61 KB
Mast be FDF Format