NCC190306_Notice of Termination_20210503

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/3/2021 9:49:17 AM (NOT Submittal)
Approve by Georgoulias, Bethany A 5/4/2021 9:03:11 AM (NOT Request Review- NCC190306)
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 5/4/2021 9:02 AM
The task was assigned to Morman, Alaina. The due date is: May 6, 2021 5:00 PM 5/3/2021 9:49 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190306
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
PAID
2021 Annual Fee Status
OPEN
K/hy be blank (if not yet billed).
Information associated
with this permit:
Project Name
Royal Village Estates Section 2 Lots
Address
Royal Coach Trail, Abbotts Creek, NC
County
Forsyth
Latitude
36.0920
Longitude
-80.0850
Permittee Listed
Eastwood Construction, LLC
Legally Responsible
Jeffrey Creighton
Individual
NC Reference No.
NCG01-2019-0306
E&SC Plan ID
Forsy-2019-039
Original NOI
11080
Tracking No.
Date COC Issued
5/17/2019
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Addional IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation Mist beRYforrrat

Project Close-out Information:
Final Close-out 1/5/2021
Inspection Approval
Project Close-out 01-05-2021 Closure Inspection Report (FORSY-
Approval 244.6KB
2019-039).pdf
Documentation
Mast be FDFforrrat
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* jeff creighton
Title * VP of Homebuilding
Organization* Eastwood Homes
Date * 05/03/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 3365879490
NOT Certification [e-mail]_20210503_0914... 357.05KB
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]