NCC190879_Notice of Termination_20201103

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/3/2020 1:01:43 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/3/2020 2:40:43 PM (NOT Request Review- NCC190879)
* Reviewer noted close-out document was dated 111712019 instead of 1111412019, but that may have
been date received. Will accept.
• The task was assigned to Georgoulias, Bethany. The due date is: November 6, 2020 5:00 PM
11/3/2020 1:01 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190879
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Stonewater S/D Phase 4, Lot 128
Address
1412 Feathery Lane, Wake Forest, NC
County
Wake
Latitude
35.9310
Longitude
-78.5023
Permittee Listed
Brandywine Homes, Inc.
Legally Responsible
Colleen Cunningham
Individual
NC Reference No.
NCG01-2019-0879
E&SC Plan ID
SEC-020073-2019
Original NOI
13184
Tracking No.
Date COC Issued
7/9/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 11/14/2019
Inspection Approval

Project Close-out SEC-020073-2019 Certificate of
Approval 159.09KB
Completion_Lot128.pdf
Documentation
Mist be FL7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowinglyrenders
inaccurate anyrecording or monitoring deice 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 notto 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* Colleen M Cunningham
Title * President
Organization* Brandywine Homes, Inc.
Date * 11 /03/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9195543351
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form DEMLR-SW sw128.pdf
NUst be Ft7F Format
Is this COC Already Ensure this CCChas not been rescinded since submttal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]
348.29KB