NCC193159_Notice of Termination_20200916

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/16/2020 8:20:42 AM (NOT Submittal)
Approve by Georgoulias, Bethany 9/17/2020 7:00:49 AM (NOT Request Review- NCC193159)
• The task was assigned to Georgoulias, Bethany. The due date is: September 21, 2020 5:00 PM
9/16/2020 8:20 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC193159
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
Information associated
with this permit:
Project Name
The Bluffs at Joyner Park Lots 29, 31, 43, 45, 47
Address
817 & 825 Park Vista Drive, 365, 360 & 352 Rocky Crest Lane,
Wake Forest, NC
County
Wake
Latitude
35.9940
Longitude
-78.5090
Permittee Listed
Jordan's Construction, Inc.
Legally Responsible
Michael Jordan
Individual
NC Reference No.
NCG01-2019-3159
E&SC Plan ID
2019-00002533
Original NOI
19400
Tracking No.
Date COC Issued
12/13/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submttal.
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 *
r Mistake or Invalid Coverage
r Other
Add Tonal Ivbre inforr ation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcunentation if applicable.
Documentation Mist beFDFfornat
Project Close-out Information:

Final Close-out 9/11/2020
Inspection Approval
Project Close-out TOWF Letter of Completion Bluff 2931434547.pdf 35.88KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.613 (i) 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 Artide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis 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 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
M,0160e19_ Jor-CJ,9J4
Type Name* Michael Jordan
Title * President
Organization* Jordan's Construction, Inc.
Date * 09/16/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9193004048
NOT Certification NC Notice of Termination Certification Form.pdf 245.61 KB
Form Mist be RY Format
Is this COCAlready Ensure this OOC has not been rescinded since subrrittal!
Rescinded?
Original Permittee CCdonKlotificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errnils
Email [e-mail]