NCC193308_Notice of Termination_20201014

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/14/2020 11:23:48 AM (NOT Submittal)
Approve by Georgoulias, Bethany 10/14/2020 11:43:47 AM (NOT Request Review- NCC193308)
• The task was assigned to Georgoulias, Bethany. The due date is: October 19, 2020 5:00 PM
10/14/2020 11:23 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC193308
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
Information associated with this permit
Project Name
Calloway Corners -Lots 15-17, 21-23 and 9419 Calloway Road (Lot
25)
Address
Carolina Road (SR1232), Quewhiffle Township, NC
County
Hoke
Latitude
35.0964
Longitude
-79.4027
Permittee Listed
A&G Residential, LLC
Legally Responsible
Jamie Godwin
Individual
NC Reference No.
NCG01-2019-3308
E&SC Plan ID
HOKE-2020-025
Original NOI
19833
Tracking No.
Date COC Issued
12/27/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submttal.
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 *
r Mistake or Invalid Coverage
r Other
Add Tonal IVbre inforr ation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcunentation if applicable.
Documentation Mist beFDFfornat
Project Close-out Information:

Final Close-out 9/22/2020
Inspection Approval
Project Close-out HOKE-2020-025-CO.pdf 58.19KB
Approval Mast be Fl7Fforrrat
Documentation
North Carolina General Statute 143-215.613 (i) 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 Artide; 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 device or method required to be operated or maintained under this Article or rules of the
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* Jamie C. Godwin
Title * Member -Manager
Organization* A&G Residential, LLC
Date * 10/14/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 910-237-7944
NOT Certification Calloway Corners 15-17 21-23 9415 NOT.pdf 645.62KB
Form Mist be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]