NCC190165_Notice of Termination_20191022

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/22/2019 9:17:42 AM (NOT Submittal)
Approve by Georgoulias, Bethany 10/23/2019 12:21:20 PM (NOT Request Review- NCC190165)
• Georgoulias, Bethany reassigned the task to Georgoulias, Bethany 10/22/2019 12:01 PM
• The task was assigned to Clark, Paul by round robin distribution 10/22/2019 9:17 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 25, 2019 5:00
PM 10/22/2019 9:17 AM

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NORTH CAROLINA
Ernvlronmental Qualily
Certificate of NCC190165
Coverage (COC) Enter the Certificate of Coverage Number
No. *
Information associated with this permit
Project Name
Seaforth Landing (Lot 6)
Address
181 Seaforth Landing, Pittsboro, NC
County
Chatham
Latitude
35.7340
Longitude
-79.0580
Permittee Listed
Poythress Construction Company, Inc.
Legally Responsible
Kevin Poythress
Individual
NC Reference No.
NCG01-2019-0165
E&SC Plan ID
2019-03333
Original NOI
10615
Tracking No.
Date COC Issued
5/2/2019
Prior Rescission
lhis field will populate only if 0OChas already been rescinded.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:
Final Close-out 10/4/2019
Inspection Approval

Project Close-out CERTIFICATE OF COMPLETION.pdf 231.21 KB
Approval Mist be FE)Fforrmt
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 deiceor 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
KhI%
Type Name* Nolan Poythress
Title * VP
Organization* Poythress Construction Company Inc
Date * 10/22/2019
Email for [e-mail]
Confirmation *
Contact Telephone* 9198106087
NOT Certification CERTIFICATE OF COMPLETION.pdf 231.21 KB
Form Mist be FCF Format