NCC192298_Notice of Termination_20201127

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/27/2020 8:19:04 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/30/2020 8:21:56 AM (NOT Request Review- NCC192298)
• The task was assigned to Georgoulias, Bethany. The due date is: December 2, 2020 5:00 PM
11 /27/2020 8:19 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192298
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Chapel Ridge Lot 635
Address
639 Golfers View, Pittsboro, NC
County
Chatham
Latitude
35.7924
Longitude
-79.2256
Permittee Listed
20/20 SITE DEVELOPMENT CO., INC.
Legally Responsible
THOMAS SIEMIENIK
Individual
NC Reference No.
NCG01-2019-2298
E&SC Plan ID
2019-08094
Original NOI
17022
Tracking No.
Date COC Issued
10/11/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 11/16/2020
Inspection Approval

Project Close-out 639 Golfers View NOT form.pdf 647.65KB
Approval Mast be FDFforrrat
Documentation
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 knowingly renders
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
f7p!(.iif .'7�Rfd1r0. `�ullsart.�spr.�
Type Name* Thomas Richard Siemienik
Title * President
Organization* 20/20 Site Development Company, Inc.
Date * 11 /27/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-338-4072
NOT Certification 639 Golfers View NOT form.pdf 647.65KB
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 Errails
Email [e-mail]