NCC201471_Notice of Termination_20200909

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/9/2020 3:26:36 PM (NOT Submittal)
Approve by Georgoulias, Bethany 9/10/2020 9:07:49 AM (NOT Request Review- NCC201471)
• The task was assigned to Georgoulias, Bethany. The due date is: September 14, 2020 5:00 PM
9/9/2020 3:26 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201471
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Stonewater s/d Phase 5 Lot 157
Address
801 Brownwich St, Wake Forest, NC
County
Wake
Latitude
36.0000
Longitude
-78.0000
Permittee Listed
Exeter Building Company
Legally Responsible
Alex Yost
Individual
NC Reference No.
NCG01-2020-1471
E&SC Plan ID
Stonewater s/d Phase 5 Lot 157
Original NOI
24243
Tracking No.
Date COC Issued
4/14/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 9/2/2020
Inspection Approval

Project Close-out 157 StoneWater Certificate of Completion
Approval 159.09KB
Sedimentation and Erosion Control.pdf
Documentation
Mist be FL7Fforrrat
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
K-Ar !vc1C
Type Name* Alex Yost
Title * Partner
Organization* Exeter Building Company
Date * 09/09/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-455-1664
NOT Certification 157 Stonewater NCG01-eNOT-Certification-Form-
Form 389.84KB
20190508-DEMLR-SW. pdf
Wst be RY 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 Notificaiton Bmils
Email [e-mail]