NCC191409_Notice of Termination_20201113

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/13/2020 10:17:08 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/16/2020 7:15:45 AM (NOT Request Review- NCC191409)
• The task was assigned to Georgoulias, Bethany. The due date is: November 18, 2020 5:00 PM
11/13/2020 10:17 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC191409
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
Information associated
with this permit:
Project Name
Forest Oaks - Phase 4, Lot 286 & 289
Address
Angel Oak Drive, Anderson Creek, NC
County
Harnett
Latitude
35.3100
Longitude
-78.9650
Permittee Listed
Caviness Land Development, Inc.
Legally Responsible
Watson Caviness
Individual
NC Reference No.
NCG01-2019-1409
E&SC Plan ID
Harne-2020-009
Original NOI
14922
Tracking No.
Date COC Issued
8/21/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 Mxe 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 3/26/2020
Inspection Approval

Project Close-out Inspection report 3.26.20.pdf 164.74KB
Approval Mist be RYforrrat
Documentation
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* Watson G Caviness
Title * President
Organization* Caviness Land Development
Date * 11 /13/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9103396330
NOT Certification NOT Cert Form.pdf 270.6KB
Form Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since submttal!
Rescinded?
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]