NCC193072_Notice of Termination_20210729

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/29/2021 9:36:38 AM (NOT Submittal)
Approve by Morman, Alaina 7/29/2021 3:13:57 PM (NOT Request Review- NCC193072)
• The task was assigned to Morman, Alaina. The due date is: August 3, 2021 5:00 PM
7/29/2021 9:36 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC193072
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status Nbybeblank (if not yet billed)
Information associated with this permit:
Project Name
H5 CABAR-2020-030 lots 166,167,211-222,227-243
Address
Stream Dale Circle, Concord, NC
County
Cabarrus
Latitude
35.4230
Longitude
-80.6450
Permittee Listed
WR dba Ryan Homes
Legally Responsible
Kevin Connery
Individual
NC Reference No.
NCG01-2019-3072
E&SC Plan ID
CABAR-2020-030
Original NOI
19035
Tracking No.
Date COC Issued
12/9/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 obtained a new COC)
Coverage *
U Mistake or Invalid Coverage
r Other
Addional
Nbre information about the basis of this request, if needed.
Explanation
All lots complete, stabilized and sold.
Supporting
Upload Supporting Dxurrentation if applicable.
Documentation
Mist be FDF fornat

Project Close-out Information:
Final Close-out 7/7/2021
Inspection Approval
Project Close-out Close-out report NCC193072.pdf 253.88KB
Approval Mast be FDFforrrat
Documentation
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
/ 1f1CIIAIW Y
Type Name* Kevin Connery
Title * Division Manager
Organization* NVR, Inc. (dba Ryan Homes)
Date * 07/29/2021
Email for [e-mail]
Confirmation *
Contact Telephone* [phone]
NOT Certification eNOT-Cert Form NCC193072_Signed.pdf 166.6KB
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Er ails
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]