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HomeMy WebLinkAboutNCC192593_Notice of Termination_20231218 Action History (UTC-05:00)Eastern Time(US&Canada) Submit by Anonymous User 12/18/2023 9:05:58 AM (NOT Submittal) Approve by Kieu Tran 12/19/2023 11:06:44 AM (NOT Request Review-NCC192593) • The task was assigned to DEMLR NCG01 NOT Review Team.The due date is: December 21,2023 5:00 PM 12/18/2023 9:05:59 AM • The task was assigned to Kieu Tran by round robin distribution 12/18/2023 9:05:59 AM Q� Notice of Termination (NOT) Request - NPDE,�tz_ Stormwater Permit for . • Use this form to submit a Notice of Termination(NOT)request for a project covered under the N.C.NPDES General Permit for Construction Activities NCGO10000(or NCG250000). If approved,the Certificate of Coverage (COC)will be rescinded. Certificate of NCC192593 Coverage(COC)No.* Enter the Certificate of Coverage Number 2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status PAID PAID PAID May be blank if N/A May be blank if N/A May be blank if N/A 2023 Annual Fee Status WAIVED May be blank if N/A Information associated with this permit: Project Name Dormie Club-Clubhouse Lots Covered by this This information is especially helpful when more lots were added with Modifications since the original permit Permit COC(if issuance. applicable) No longer visible on the initial form(data not captured from initial application) Address Beulah Hill Church Rd.,West End, NC County Moore Latitude 35.2601 Longitude -79.5061 Permittee Listed Sampson Construction Co., Inc. Legally Responsible Ben Huck Individual NC Reference No. NCGO1-2019-2593 E&SC Plan ID MOORE-2020-011 Original NOI Tracking 17919 No. Date COC Issued 11/12/2019 Prior Rescission Date Date populates only if COC was already rescinded at time of submittal. Reason for Rescission/Termination Request: Reason for Project Closed-Out Termination of Sale(Another Owner/Operator obtained new COC) Coverage* Mistake or Invalid Coverage Other Additional More information about the basis of this request,if needed. Explanation Supporting Upload Supporting Documentation if applicable. Documentation Must be PDF format Project Close-out Information: Erosion Control Plan 10/18/2022 Close-out Date Erosion Control Plan DEQ SWPPP Final Inspection.pdf 36.38KB Close-out Must be PDF format Documentation North Carolina General Statute 143-215.6B(i)provides that: Any person who knowingly makes any false 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 device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars($10,000). * 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 OZ(!hir C'�yyllll Type Name* Justin J. Hall Title* Senior Project Manager Organization* Sampson Construction Co., Inc. Date* 12/18/2023 Email for justin.hall@sampson-construction.com Confirmation* Contact Telephone* 402-416-6569 NOT Certification DEQ SWPPP NOT Form-Corrected Legally Form 689.74K6 Responsible Person.pdf Must be PDF Format Is this COC Already Ensure this COC has not been rescinded since submittal! Rescinded? Additional Email CC'd on Notification Emails (Optional) Original Permittee cc'd on Notification Emails Email ben.huck@sampson-construction.com Original Site Contact cc'd on Notificaiton Emails Email peter.erickson@sampson-construction.com