NCC192844_Notice of Termination_20200626

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/26/2020 12:29:39 PM (NOT Submittal)
Approve by Georgoulias, Bethany 6/26/2020 2:11:31 PM (NOT Request Review- NCC192844)
• The task was assigned to Georgoulias, Bethany. The due date is: July 1, 2020 5:00 PM
6/26/2020 12:29 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192844
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Raintree Country Club Bunker Renovations
Address
8600 Raintree Lane, Charlotte, NC
County
Mecklenburg
Latitude
35.0870
Longitude
-80.7870
Permittee Listed
Raintree Country Club
Legally Responsible
Jim Troutman
Individual
NC Reference No.
NCG01-2019-2844
E&SC Plan ID
LDGP-2019-00237
Original NOI
18609
Tracking No.
Date COC Issued
11/21/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 We 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 6/25/2020
Inspection Approval

Project Close-out Raintree_grading permit NOT.pdf 82.29KB
Approval Mast be FDFforrrat
Documentation
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).
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* Jim Troutman
Title * General Manager
Organization* Raintree Country Club
Date * 06/26/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 7046504859
NOT Certification NOT-Signed.pdf 468.8KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since submttal!
Rescinded?
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]