NCC193044_Notice of Termination_20210903

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/3/2021 11:57:33 AM (NOT Submittal)
Approve by Morman, Alaina 9/8/2021 12:34:57 PM (NOT Request Review- NCC193044)
• The task was assigned to Morman, Alaina. The due date is: September 8, 2021 5:00 PM
9/3/2021 11:57 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC193044
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
22 Davie LLC
Address
1217 Harold Andrews Road, Siler City, NC
County
Chatham
Latitude
35.7514
Longitude
-79.4537
Permittee Listed
Ellington Contracting, Inc.
Legally Responsible
Isaac Ellington
Individual
NC Reference No.
NCG01-2019-3044
E&SC Plan ID
CHATH-2020-004
Original NOI
19102
Tracking No.
Date COC Issued
12/16/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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
Additional Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 8/24/2021
Inspection Approval
Project Close-out LEE-2020-004_20210824_INSP RPT_22 davie
Approval 36.49KB
Ilc.pdf
Documentation
Mist be Ft7Fforrrat
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
14mG fffU7t k
Type Name* Isaac Ellington
Title * President
Organization* Ellington Contracting, Inc
Date * 09/03/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 919-548-1132
NOT Certification NCDEQ NOT form.pdf
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonWificationBails
Email [e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]
570.88KB