NCC203570_Notice of Termination_20201203

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/3/2020 8:43:48 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/3/2020 10:46:21 AM (NOT Request Review- NCC203570)
• The task was assigned to Georgoulias, Bethany. The due date is: December 8, 2020 5:00 PM
12/3/2020 8:43 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC203570
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Waterside Lane
Address
Daniel Boone Trail, Henderson, NC
County
Vance
Latitude
36.4190
Longitude
-78.3730
Permittee Listed
Faulkner Grading and Landscaping, Inc.
Legally Responsible
Alan Faulkner
Individual
NC Reference No.
NCG01-2020-3570
E&SC Plan ID
Vance-2020-005
Original NOI
29969
Tracking No.
Date COC Issued
8/18/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 Mxe inforrration about the basis of this request, if needed.
Explanation
Supporting upload Supporting Qbcurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 11/24/2020
Inspection Approval

Project Close-out VANCE-2020-005_20201124_lnspRpt.pdf 173.87KB
Approval Mist 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
71601 A Ir"11
Type Name* Alan D. Faulkner
Title * president
Organization* Faulkner Grading and Landscaping, Inc.
Date * 12/03/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 252-430-9525
NOT Certification Waterside NOT Cert. Form.pdf 323.41 KB
Form Mist be PDF 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]