NCC200381_Notice of Termination_20201203

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/3/2020 2:02:59 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/4/2020 10:34:24 AM (NOT Request Review- NCC200381)
• The task was assigned to Georgoulias, Bethany. The due date is: December 8, 2020 5:00 PM
12/3/2020 2:03 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200381
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Lot 120 Carlton Pointe, Phase 3B
Address
705 Strathwood Way, Rolesville, NC
County
Wake
Latitude
35.9042
Longitude
-78.4730
Permittee Listed
Brandywine Homes, Inc.
Legally Responsible
Colleen Cunningham
Individual
NC Reference No.
NCG01-2020-0381
E&SC Plan ID
SEC-030806-2019
Original NOI
21247
Tracking No.
Date COC Issued
1/31/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 6/18/2020
Inspection Approval

Project Close-out SEC-030806-2019_Certificate of Completion_Single
Approval 165.1 KB
Lot —Permit Closure-6-18-20.pdf
Documentation
Mast be FDFforrrat
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* Colleen M Cunningham
Title * President
Organization* Brandywine Homes, Inc.
Date * 12/03/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9195543351
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form DEMLR-SW cp120.pdf
Wst be Ft7F Forrrat
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 Notificaiton Bmils
Email
[e-mail]
345.59KB