NCC192482_Notice of Termination_20200522

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/22/2020 8:28:07 AM (NOT Submittal)
Approve by Georgoulias, Bethany 5/22/2020 11:43:59 AM (NOT Request Review- NCC192482)
• The task was assigned to Georgoulias, Bethany. The due date is: May 27, 2020 5:00 PM
5/22/2020 8:28 AM

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NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192482
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Blackbridge Subdivision Phase Two Lot 15
Address
Low Oak Ct / Long Lake Drive, Rockfish, NC
County
Cumberland
Latitude
34.9501
Longitude
-78.9822
Permittee Listed
Caviness Land Development, Inc.
Legally Responsible
Watson Caviness
Individual
NC Reference No.
NCG01-2019-2482
E&SC Plan ID
CUMBE-2020-053
Original NOI
17449
Tracking No.
Date COC Issued
10/29/2019
Prior Rescission
Date populates only if OOCwas already rescinded at tirre of subaittal.
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 * O Mistake or Invalid Coverage
r Other
Addional Mxe inforrration about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 5/12/2020
Inspection Approval

Project Close-out BV15 Release Form.pdf
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
58.03KB
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).
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
Type Name* Watson G Caviness
Title * President
Organization* Caviness Land Development
Date * 05/22/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9103396330
NOT Certification NOT Cert Form.pdf 294.3KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]