NCC193169_Notice of Termination_20210102

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/2/2021 5:15:59 PM (NOT Submittal)
Approve by Georgoulias, Bethany 1/4/2021 9:40:25 AM (NOT Request Review- NCC193169)
• The task was assigned to Georgoulias, Bethany. The due date is: January 7, 2021 5:00 PM
1 /2/2021 5:16 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC193169
Coverage (COC) Enter the Certificate of Coverage Nimber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Gordon Park Phase 3 lots 19,90,118
Address
Gordon Park Boulevard, Clayton Township, NC
County
Johnston
Latitude
35.6233
Longitude
-78.3956
Permittee Listed
Cates Building Inc.
Legally Responsible
Christopher Cates
Individual
NC Reference No.
NCG01-2019-3169
E&SC Plan ID
JC# 17-027-P
Original NOI
19448
Tracking No.
Date COC Issued
12/23/2019
Prior Rescission
Date populates only if OOCwas already rescinded at tirre of submittal.
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 *
O 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 12/14/2020
Inspection Approval
Project Close-out GD19,90&118 Closeout Letter.pdf 354.25KB
Approval Mast be FDFforrrat
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 ofthe
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
Type Name* Christopher E. Cates
Title * President
Organization* Cates Building Inc
Date * 01 /02/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9107787902
NOT Certification GD19,90,118 NOT. pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
733.25KB