NCC193317_Notice of Termination_20200916

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/16/2020 9:20:18 AM (NOT Submittal)
Approve by Georgoulias, Bethany 9/17/2020 7:07:07 AM (NOT Request Review- NCC193317)
• The task was assigned to Georgoulias, Bethany. The due date is: September 21, 2020 5:00 PM
9/16/2020 9:20 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC193317
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Knightdale Station Lot 203, 205, 208
Address
705 Twin Star, 604 Gold Coast, 616 Gold Coast, Town of
Knightdale, NC
County
Wake
Latitude
35.7980
Longitude
-78.4620
Permittee Listed
McKee Homes, LLC
Legally Responsible
Kelsey Rivera
Individual
NC Reference No.
NCG01-2019-3317
E&SC Plan ID
SEC - 028813-2019
Original NOI
19899
Tracking No.
Date COC Issued
2/4/2020
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Date populates only if COCwas already rescinded at tirre of submttal.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 information about the basis of this request, if needed.
Explanation
Supporting upload Supporting DDcunentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:

Final Close-out 9/11/2020
Inspection Approval
Project Close-out SEC-028813-2019 Certificate of
Approval Completion_MultipleLots_PermitClosure 9-11- 165.98KB
Documentation
20.pdf
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (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 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 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 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
Type Name* Kelsey Rivera
Title * Pre Construction Coordinator
Organization* McKee Homes, LLC
Date * 09/16/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9104757100
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form DEMLR-SW.pdf
Mast be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee 0Cd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Wtificaiton Bmils
Email [e-mail]
219.82KB