NCC201821_Notice of Termination_20200925

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/25/2020 10:33:30 AM (NOT Submittal)
Approve by Georgoulias, Bethany 9/28/2020 7:43:57 AM (NOT Request Review- NCC201821)
• The task was assigned to Georgoulias, Bethany. The due date is: September 30, 2020 5:00 PM
9/25/2020 10:33 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201821
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Cypress Lakes Village Phase 3 - Lots 383 & 448
Address
Debut Ave/Seattle Slew Ln, Grays Creek, NC
County
Cumberland
Latitude
34.9209
Longitude
-78.8984
Permittee Listed
Caviness Land Development, Inc
Legally Responsible
Watson Caviness
Individual
NC Reference No.
NCG01-2020-1821
E&SC Plan ID
CUMBE-2020-160
Original NOI
24955
Tracking No.
Date COC Issued
5/5/2020
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 9/2/2020
Inspection Approval

Project Close-out Cypress Lakes Village Phase 3 -Lots 383 & 448.pdf 58.21 KB
Approval Mast be RYforrrat
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* Watson G Caviness
Title * President
Organization* Caviness Land Development
Date * 09/25/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9193396330
NOT Certification CG383,448 Cert Form.pdf
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee 0Cd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]
300.11 KB