NCC201674_Notice of Termination_20201125

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/25/2020 5:06:41 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/30/2020 10:30:02 AM (NOT Request Review- NCC201674)
• The task was assigned to Georgoulias, Bethany. The due date is: November 30, 2020 5:00 PM
11 /25/2020 5:06 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201674
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Thompson St Subdivision - Lot 19
Address
235 Cottage Way, Pittsboro, NC
County
Chatham
Latitude
35.7239
Longitude
-79.1606
Permittee Listed
Chatham Development One, LLC
Legally Responsible
Tim Smith
Individual
NC Reference No.
NCG01-2020-1674
E&SC Plan ID
2020-02721
Original NOI
24712
Tracking No.
Date COC Issued
4/24/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 11/18/2020
Inspection Approval

Project Close-out CERTIFICATE OF COMPLETION.pdf 175.83KB
Approval Mist 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 ofthe
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* Tim Smith
Title * Manager
Organization* Chatham Development One, LLC
Date * 11 /25/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-481-3000 x 5
NOT Certification NC G01 eNOT Thompson St Subdivision - Lot 19 -
Form 56.29KB
signed.pdf
Mast be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]