NCC191318_Notice of Termination_20200609

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/9/2020 10:54:41 AM (NOT Submittal)
Approve by Georgoulias, Bethany 6/10/2020 11:09:58 AM (NOT Request Review- NCC191318)
• The task was assigned to Georgoulias, Bethany. The due date is: June 12, 2020 5:00 PM
6/9/2020 10:54 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191318
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Seaforth Landing (Lot 5)
Address
145 Seaforth Landing Drive, Pittsboro, NC
County
Chatham
Latitude
35.7360
Longitude
-79.0610
Permittee Listed
Poythress Construction Company, Inc.
Legally Responsible
Kevin Poythress
Individual
NC Reference No.
NCG01-2019-1318
E&SC Plan ID
2019-06593
Original NOI
14635
Tracking No.
Date COC Issued
8/13/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * O Mistake or Invalid Coverage
r Other
Addional We inforrration about the basis of this request, if needed.
Explanation
Supporting upload Supporting Qbcurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 6/5/2020
Inspection Approval

Project Close-out CERTIFICATE OF COMPLETION (004).pdf 233.47KB
Approval Mist be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording or monitoring deice or method required to be operated or maintained under this Article or rules ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto 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
Type Name* Nolan Poythress
Title * VP
Organization* Poythress Construction Company Inc
Date * 06/09/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9194635403
NOT Certification Lot 5 Seaforth NOT Certification Form.pdf 265.28KB
Form Mist be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]