NCC190546_Notice of Termination_20210623

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/23/2021 10:42:39 AM (NOT Submittal)
Approve by Morman, Alaina 6/24/2021 11:19:59 AM (NOT Request Review- NCC190546)
• The task was assigned to Morman, Alaina. The due date is: June 28, 2021 5:00 PM
6/23/2021 10:42 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190546
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
ivby be blank (if not yet billed).
Information associated with this permit:
Project Name
Fox Chase Subdivision Phase 1
Address
NCHwy 62, Trinity, NC
County
Randolph
Latitude
35.8764
Longitude
-80.0194
Permittee Listed
Michael Plyler
Legally Responsible
Michael Plyler
Individual
NC Reference No.
NCG01-2019-0546
E&SC Plan ID
RANDO-2019-031
Original NOI
11908
Tracking No.
Date COC Issued
6/7/2019
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
f Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
F Other NEW OWNER- SOLD TO "LEOTERRA COLLETT FARM LLC"
Addional IVbre information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation Notice of Termination and current Inspection report-
923.16KB
1.pdf
Mast be FDFformat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFformat
Approval
Documentation
North Carolina General Statute 143-215.6E (i) 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 of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
I7 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* Michael Plyler
Title * Previous owner of Land
Organization* n/a
Date * 06/23/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-848-6714
NOT Certification Notice of Termination and current Inspection report -
Form 1.pdf 923.16KB
Mast be RY Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)

Original Permittee CCdonNotificationEn-ails
Email [e-mail]
Original Site Contact GCd on Notificaiton Erails
Email [e-mail]