NCC190129_Notice of Termination_20190909

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 8/30/2019 11:14:10 AM (NOT Submittal)
Approve by Morman, Alaina 9/9/2019 12:47:39 PM (NOT Request Review- NCC190129)
• The task was assigned to Morman, Alaina by round robin distribution 8/30/2019 11:14 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: September 4, 2019 5:00
PM 8/30/2019 11:14 AM

Jn a1LUUFF1Widl1
NORTH CAROLINA
Ernvlronmentol qualily
Certificate of NCC190129
Coverage (COC) Enter the Certificate of Coverage Nurrber
No. *
Information associated with this permit
Project Name
Quail Hollow Erosion Control
Address
3700 Gleneagles Road, Charlotte, NC
County
Mecklenburg
Latitude
37.2723
Longitude
-81.4413
Permittee Listed
Quail Hollow Country Club
Legally Responsible
Tom Deloaer
Individual
NC Reference No.
NCG01-2019-0129
E&SC Plan ID
LDGP-2019-00081
Original NOI
10482
Tracking No.
Date COC Issued
4/30/2019
Prior Rescission
This field will populate only if 0OChas already been rescinded.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Addional Nbre information about the basis of this request, if needed.
Explanation
Supporting 1pload Supporting Documentation if applicable.
Documentation WstbeFDFformat
Project Close-out Information:
Final Close-out 8/16/2019
Inspection Approval

Project Close-out LDGP-2019-00081_Notice of Termination.pdf 1.16MB
Approval Mist be FDFfonrat
Documentation
North Carolina General Statute 143-215.6B (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 knowinglymakes 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 deviceor 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).
17 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
�0c4MLa46 At kWaas"-
Type Name* Nicholas M. Mazzella
Title * President
Organization* The Mazzella Partnership LLC
Date * 08/30/2019
Email for [e-mail]
Confirmation *
Contact Telephone* 7046504859
NOT Certification LDGP-2019-00081_Notice of Termination.pdf 1.16MB
Form Mast be FDF Format