NCC190341_Notice of Termination_20210517

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/17/2021 10:56:49 AM (NOT Submittal)
Approve by Morman, Alaina 5/23/2021 9:14:22 AM (NOT Request Review- NCC190341)
• The task was assigned to Morman, Alaina. The due date is: May 20, 2021 5:00 PM
5/17/2021 10:56 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190341
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
Hamilton Farm
Address
8805 Castleberry Rd, Apex, NC
County
Wake
Latitude
35.7617
Longitude
-78.9344
Permittee Listed
John C Sanders & Company
Legally Responsible
John Sanders
Individual
NC Reference No.
NCG01-2019-0341
E&SC Plan ID
SEC-016225-2019
Original NOI
11240
Tracking No.
Date COC Issued
5/21/2019
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Cate populates only if COCwas already rescinded at time of submittal.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 12/9/2020
Inspection Approval
Project Close-out Hamilton SEC-016225-2019-Certificate of
Approval 133.81 KB
Completion_Hamilton Farms.pdf
Documentation
Mast be Ft7Fforrrat
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 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 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* Shaben Khoury
Title * Construction Manager
Organization * John C Sanders & Company, LLC
Date * 05/17/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9198969440
NOT Certification Hamilton NOT Certification Form.pdf
Form Mast be PDF Forrrst
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]
505.56KB