NCC191617_Notice of Termination_20201123

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/23/2020 2:28:20 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/24/2020 7:53:30 AM (NOT Request Review- NCC191617)
• The task was assigned to Georgoulias, Bethany. The due date is: November 26, 2020 5:00 PM
11 /23/2020 2:28 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191617
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Wendell Falls Phase 5F-902-917
Address
1512 Mallard Trace, Wendell, NC
County
Wake
Latitude
35.7615
Longitude
-78.4277
Permittee Listed
Capitol City Homes LLC
Legally Responsible
Jason Morrow
Individual
NC Reference No.
NCG01-2019-1617
E&SC Plan ID
SEC-023432-2019
Original NOI
15337
Tracking No.
Date COC Issued
8/28/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 11/13/2020
Inspection Approval

Project Close-out SEC-023432-2019 Certificate of
Approval Completion_MultipleLots_PermitClosure_11-13- 165.6KB
Documentation
20.pdf
Mast be FDFforrrat
North Carolina General Statute 143-215.613 (i) 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 Artide or a rule implementing this Artide; 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 any recording or monitoring device or method required to be operated or maintained under this Artide or rules of the
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* Jason Morrow
Title * Managing Partner
Organization* Capitol City Homes
Date * 11/23/2020
Email for [e-mail]
Confirmation *
Contact Telephone* Managing Partner
NOT Certification NCGO1 Notice of Termination (NOT) Certificate
Form Form.pdf
Mast be FDF Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCdonWificationBmils
Email [e-mail]
Original Site Contact 0Cd on Nutificaiton BTails
Email [e-mail]
26.11 KB