NCC190197_Notice of Termination_20201028

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/28/2020 6:30:38 AM (NOT Submittal)
Approve by Georgoulias, Bethany 10/28/2020 7:41:38 AM (NOT Request Review- NCC190197)
p Verified original permitted entity organization was correct; applicant inadvertently listed different one. 1
is the same individual and matches City's close-out documentation. See e-mail correspondence with NOT
signed certification form.
• The task was assigned to Georgoulias, Bethany. The due date is: November 2, 2020 5:00 PM
10/28/2020 6:30 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190197
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Atlas Urban Homes Redevelopment
Address
3117 Whiting Avenue, Charlotte, NC
County
Mecklenburg
Latitude
35.2425
Longitude
-80.8023
Permittee Listed
Atlas Urban Homes, LLC
Legally Responsible
Tim McCollum
Individual
NC Reference No.
NCG01-2019-0197
E&SC Plan ID
LDGP-2019-00078
Original NOI
10749
Tracking No.
Date COC Issued
5/7/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 10/26/2020
Inspection Approval

Project Close-out Grading PermitNoticeOf-Fermination_20201026_06... 84.45KB
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* Timothy McCollum
Title * Principal
Organization* Revolve Residential
Date * 10/28/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 7049652535
NOT Certification Scan.pdf 688.43KB
Form Mast be FCF 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]