NCC190570_Notice of Termination_20200130

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/30/2020 10:52:37 AM (NOT Submittal)
Approve by Georgoulias, Bethany 2/3/2020 8:44:39 AM (NOT Request Review- NCC190570)
• Georgoulias, Bethany reassigned the task to Georgoulias, Bethany 1/31/2020 2:41 PM
. The task was assigned to Farkas, Jim J by round robin distribution 1/30/2020 10:52 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: February 4, 2020 5:00
PM 1/30/2020 10:52 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190570
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Ladera Subdivision (Creek Slope
Stabilization)
Address
1208 Ladera Drive, Waxhaw, NC
County
Union
Latitude
35.0000
Longitude
-81.0000
Permittee Listed
Ladera Owner's Association
Legally Responsible
William DeForest
Individual
NC Reference No.
NCG01-2019-0570
E&SC Plan ID
UNION-2019-079
Original NOI
12032
Tracking No.
Date COC Issued
6/11/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submttal.
Date
Reason for Rescission/Termination Request:
Reason for
F Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Add Tonal IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcunentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:

Final Close-out 1/13/2020
Inspection Approval
Project Close-out NC DEQ Final Inspection.pdf 24.76KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.613 (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 device 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).
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
llr�2s9r•
Type Name* William DeForest
Title * Land Development Manager
Organization * Ladera's Owner Association
Date * 01 /30/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 704-759-6000
NOT Certification e-NOT Cert Form.pdf 358.31 KB
Form Mist be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?