NCC190617_Notice of Termination_20201221

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/21/2020 3:42:53 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/21/2020 3:51:48 PM (NOT Request Review- NCC190617)
• The task was assigned to Georgoulias, Bethany. The due date is: December 24, 2020 5:00 PM
12/21/2020 3:43 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190617
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status WAIVED
2021 Annual Fee Status N/A
Information associated with this permit
Project Name
Cameron Crossing
Address
Enterprise Drive, Clayton, NC
County
Johnston
Latitude
35.6604
Longitude
-78.4737
Permittee Listed
Forsyth Investments Co LLC
Legally Responsible
Gordon Poulsen
Individual
NC Reference No.
NCG01-2019-0617
E&SC Plan ID
JC# 18-031-P
Original NOI
12279
Tracking No.
Date COC Issued
6/15/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
F Sale (Another Owner/Operator will apply for a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Ad d i o n a I Ivbre information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation Deed (recorded) (Forsyth to Forestar) (BK5433- 11 5.8KB
PG686).pdf
Deed (recorded) (Forsyth to Forestar) (BK5433- 11 5.8KB
PG686).pdf
NUst be FDFforrrat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFforrrat
Approval
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 of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to 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
�v�d��rporrtct{�
Type Name* Gordon Poulsen
Title * Managing Member
Organization* Forsyth Investments Company, LLC
Date * 12/21 /2020
Email for [e-mail]
Confirmation *
Contact Telephone* 19193456805
NOT Certification NOT Cameron Crossing.pdf 218.45KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]

Original Permittee GCd on Notification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]