NCC191127_Notice of Termination_20191017

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/17/2019 9:01:41 AM (NOT Submittal)
Approve by Garcia, Lauren V 10/17/2019 9:26:59 AM (NOT Request Review- NCC191127)
• The task was assigned to Garcia, Lauren V by round robin distribution 10/17/2019 9:01 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 22, 2019 5:00
PM 10/17/2019 9:01 AM

STME
NORTH CAROLINA
Ernvlronmental Qualily
Certificate of
NCC191127
Coverage (COC)
Enter the Certificate of Coverage Nurrber
No. *
Information associated
with this permit:
Project Name
Blackbridge Subdivision Phase Two Lot 14
Address
4454 Low Oak Court, rockfish, NC
County
Cumberland
Latitude
35.0000
Longitude
-79.0000
Permittee Listed
Caviness Land Development, Inc.
Legally Responsible
Watson Caviness
Individual
NC Reference No.
NCG01-2019-1127
E&SC Plan ID
CUMBE-2019-126
Original NOI
14117
Tracking No.
Date COC Issued
7/30/2019
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This field will populate only if 0OChas already been rescinded.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 Nbre information about the basis of this request, if needed.
Explanation
Supporting 1pload Supporting Documentation if applicable.
Documentation WstbeFDFformat
Project Close-out Information:
Jn a1LUUFF1Widl1
Final Close-out 8/8/2019
Inspection Approval

Project Close-out Blackbridge Subdivision Phase Two Lot 14.pdf 57.53KB
Approval lutist be FDFfornat
Documentation
North Carolina General Statute 143-215.6B (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Article or a rule implementing this Article; or who 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 deviceor method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 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
V� rdeW C7C`' WVd
Type Name* Watson G Caviness
Title * President
Organization* Caviness Land Development, Inc
Date * 10/17/2019
Email for [e-mail]
Confirmation *
Contact Telephone* 910-339-6330
NOT Certification Xerox Scan.pdf 23.99KB
Form Mist be FDF Forrret