NCC191348_Notice of Termination_20201209

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/9/2020 2:25:15 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/9/2020 2:52:47 PM (NOT Request Review- NCC191348)
• The task was assigned to Georgoulias, Bethany. The due date is: December 14, 2020 5:00 PM
12/9/2020 2:25 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191348
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee OPEN
Status
Information associated with this permit:
Project Name
Lots 1A, 1B, and 1C in the William & Megumi Holley Subdivision
Address
Grimes, Seventy First Township, NC
County
Cumberland
Latitude
34.9942
Longitude
-78.0335
Permittee Listed
Pride Homes, Inc.
Legally Responsible
Joseph Perkins
Individual
NC Reference No.
NCG01-2019-1348
E&SC Plan ID
CUMBE-2019-156
Original NOI
14756
Tracking No.
Date COC Issued
8/19/2019
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Cute populates only if CCCwas already rescinded at tirre of submttal.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 11/16/2020
Inspection Approval
Project Close-out Lots 1A, 1B & 1C in the William & Megumi Holley
Approval 58.34KB
Subdivision.pdf
Documentation
Mast be FL7Fforrrat
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 Arficle; 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 of the
Commission implementing this Arficle 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 * joe perkins
Title * owner
Organization* PRIDE HOMES
Date * 12/09/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9107512402
NOT Certification HPSCAN_20201119174205611_2020-11-
Form 529.29KB
19_174357235. pdf
Wst be RY Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Notification Errails
Email office. [e-mail]
Original Site Contact CCd on Notificaiton Erails
Email [e-mail]