NCC193115_Notice of Termination_20201208

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/8/2020 8:21:20 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/9/2020 1:39:50 PM (NOT Request Review- NCC193115)
• The task was assigned to Georgoulias, Bethany. The due date is: December 11, 2020 5:00 PM
12/8/2020 8:21 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC193115
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee OPEN
Status
Information associated with this permit:
Project Name
EC Plan for Lots 81, 82, 92, and 93 at The Sentinels
Address
5109, 5113, 5137, and 5141 Thruway Road, Grays Creek, NC
County
Cumberland
Latitude
34.9083
Longitude
-78.8678
Permittee Listed
Pride Homes, Inc.
Legally Responsible
Joseph Perkins
Individual
NC Reference No.
NCG01-2019-3115
E&SC Plan ID
CUMBE-2020-049
Original NOI
19248
Tracking No.
Date COC Issued
12/10/2019
Prior Rescission
Cute populates only if CCCwas already rescinded at tirre of submttal.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
Addional IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcurrentation if applicable.
Documentation NLstbeFOFformat
Project Close-out Information:

Final Close-out 11/10/2020
Inspection Approval
Project Close-out Lots 81, 82, 92 & 93 in The Sentinels (1).pdf 58.36KB
Approval Mast be Ft7Fforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Pnyperson 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 any recording or monitoring deice 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 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* joe Perkins
Title * owner
Organization* PRIDE HOMES
Date * 12/08/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9107512402
NOT Certification HPSCAN_20201208131504087_2020-12-
Form 08_131639645.pdf
Mast be RY Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Notification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
491.57KB