NCC205310_Notice of Termination_20201124

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/24/2020 9:49:33 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/24/2020 9:58:01 AM (NOT Request Review- NCC205310)
• The task was assigned to Georgoulias, Bethany. The due date is: November 27, 2020 5:00 PM
11/24/2020 9:49 AM

1 �
NORTH CAROLINA
Enrlronmenral quallly
Certificate of NCC205310
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Quaker Field Subdivision
Address
Robbins Country Road, Archdale, NC
County
Randolph
Latitude
35.8778
Longitude
-79.9558
Permittee Listed
P.R.O. Development LLC
Legally Responsible
Papillon Pipes
Individual
NC Reference No.
NCG01-2020-5310
E&SC Plan ID
COA-2021-017
Original NOI
36505
Tracking No.
Date COC Issued
11/20/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * F Mistake or Invalid Coverage
r Other
Add ional
Nbre inforrration about the basis of this request, if needed.
Explanation
Typo in email address for contact person
Supporting
upload Supporting Docurrentation if applicable.
Documentation
Mist beFDFforrrat
Project Close-out Information:
Final Close-out
Inspection Approval

Project Close-out Mast beFDFformat
Approval
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
M� L�I_.l
Type Name* Pino Pipes
Title * President
Organization* P.R.O. Development, LLC
Date * 11 /24/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 3363076809
NOT Certification img20201124_09480448.pdf 1.07MB
Form Mast be FDF 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]