NCC193367_Notice of Termination_20201221

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/21/2020 10:03:17 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/21/2020 3:44:56 PM (NOT Request Review- NCC193367)
• The task was assigned to Georgoulias, Bethany. The due date is: December 24, 2020 5:00 PM
12/21/2020 10:03 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC193367
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status
N/A
Information associated
with this permit:
Project Name
Windfall - Lot 66
Address
814 Ocoee Falls Drive, Pittsboro, NC
County
Chatham
Latitude
35.7430
Longitude
-79.0670
Permittee Listed
N/A
Legally Responsible
Brad McRae
Individual
NC Reference No.
NCG01-2019-3367
E&SC Plan ID
2019-09634
Original NOI
19878
Tracking No.
Date COC Issued
1/2/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 12/17/2020
Inspection Approval
Project Close-out CERTIFICATE OF COMPLETION —Windfall Lot
Approval 66.pdf 290.96KB
Documentation
Mist be FDFforrrat
North Carolina General Statute 143-215.66 (1) 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 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 anyrecording 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 notto exceed ten thousand
dollars ($10,000).
rJ 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* Brad McRae
Title * Landowner
Organization* N/A
Date * 12/21 /2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9192253266
NOT Certification NOT Cert Signed.pdf
Form Mast be FDF Forrrat
Is this COC Already Ensure this OCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification BTails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact OCd on Notificaiton BTails
Email [e-mail]
269.61 KB