NCC193182_Notice of Termination_20210104

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/4/2021 2:40:58 PM (NOT Submittal)
Approve by Georgoulias, Bethany 1/4/2021 4:14:43 PM (NOT Request Review- NCC193182)
• The task was assigned to Georgoulias, Bethany. The due date is: January 7, 2021 5:00 PM
1/4/2021 2:41 PM

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NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC193182
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Woodbridge Meadows, Phase V-Lots 29-31 & 44-47
Address
Lenity Lane, Jonesboro Township, NC
County
Lee
Latitude
35.0000
Longitude
-79.0000
Permittee Listed
H&H Constructors, Inc.
Legally Responsible
Brian Walker
Individual
NC Reference No.
NCG01-2019-3182
E&SC Plan ID
LEE-2020-016
Original NOI
19348
Tracking No.
Date COC Issued
12/13/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 12/23/2020
Inspection Approval
Project Close-out LEE-2020-016 CO.pdf
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
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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
of,��11'
Type Name* Brian Walker
Title * Agent
Organization* H&HConstructors, Inc.
Date * 01 /04/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 910-486-4864
NOT Certification WMD NOT.pdf
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)
Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
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