NCC192820_Notice of Termination_20210121

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/21/2021 2:08:13 PM (NOT Submittal)
Approve by Morman, Alaina 1/25/2021 3:36:46 PM (NOT Request Review- NCC192820)
• The task was assigned to Morman, Alaina. The due date is: January 26, 2021 5:00 PM
1 /21 /2021 2:08 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192820
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status PAST DUE
2021 Annual Fee Status Nbybeblank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Reviewstep) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit
Project Name
Carlton Pointe, Phase 3A Lot 139
Address
764 Strathwood Way, Rolesville, NC
County
Wake
Latitude
35.9080
Longitude
-78.4740
Permittee Listed
Brandywine Homes, Inc.
Legally Responsible
Colleen Cunnningham
Individual
NC Reference No.
NCG01-2019-2820
E&SC Plan ID
SEC-028036-2019
Original NOI
18552
Tracking No.
Date COC Issued
11/20/2019
Prior Rescission
Cate populates only if CDC was already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
C Project Closed -Out
Termination of
Q Sale (Another Owner/Operator will apply for a new COC)
Coverage *
a Mistake or Invalid Coverage
0 Other

Add ional Nbre infornation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation Mast beFDFforrat
Project Close-out Information:
Final Close-out 12/21/2020
Inspection Approval
Project Close-out SEC-028036-2019certofcompletion (2).pdf 240.25KB
Approval Mast be FDFfornat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed 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 under this Atcle; 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 Atcle shall be guiltyofa Class 2 misdemeanor which may include 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* Colleen M Cunningham
Title * President
Organization* Brandywine Homes, Inc.
Date * 01 /21 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9195543351
NOT Certification NCG01-eNOT-Certification-Form-20201215-
Form 990.3KB
DEMLR-SW cp139.pdf
Mast be RY Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]

Original Permittee 0Cd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]