NCC192417_Notice of Termination_20200821

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/21/2020 3:29:06 PM (NOT Submittal)
Approve by Georgoulias, Bethany 8/24/2020 7:44:18 AM (NOT Request Review- NCC192417)
• The task was assigned to Georgoulias, Bethany. The due date is: August 26, 2020 5:00 PM
8/21 /2020 3:29 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192417
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Willoughby lot 43
Address
516 Adkins Ridge Road, Rolesville, NC
County
Wake
Latitude
35.9290
Longitude
-78.4710
Permittee Listed
The Drees Company
Legally Responsible
Jerry Dean
Individual
NC Reference No.
NCG01-2019-2417
E&SC Plan ID
SEC-026228-2019
Original NOI
17307
Tracking No.
Date COC Issued
10/23/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 7/23/2020
Inspection Approval

Project Close-out WBY 43 SEC-026228-2019 Certificate of
Approval 163.55KB
Completion_7-23-20.pdf
Documentation
Mast be Fl7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guilty ofa Class 2 misdemeanor which may include 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* Jerry Dean
Title * Division President
Organization* The Drees Company
Date * 08/21 /2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9198449288
NOT Certification WBY43 NOT Certification Form. pdf
Form Mast be PDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Kotificaiton Errails
Email [e-mail]
336.09KB