NCC192084_Notice of Termination_20201207

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/7/2020 3:15:23 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/8/2020 7:46:40 AM (NOT Request Review- NCC192084)
• The task was assigned to Georgoulias, Bethany. The due date is: December 10, 2020 5:00 PM
12/7/2020 3:15 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC192084
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee
OPEN
Status
Information associated
with this permit:
Project Name
Brook Hollow Duplex
Address
2309 A DOVEDALE DR, Greenville, NC
County
Pitt
Latitude
35.5823
Longitude
-77.4269
Permittee Listed
E H Blount Construction
Legally Responsible
Hunter Blount
Individual
NC Reference No.
NCG01-2019-2084
E&SC Plan ID
ESCP-2019-0052
Original NOI
16300
Tracking No.
Date COC Issued
10/8/2019
Prior Rescission
Cute populates only if CCCwas already rescinded at tirre of submttal.
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 *
r Mistake or Invalid Coverage
r Other
Addional IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting DDcurrentation if applicable.
Documentation NLstbeFOFformat
Project Close-out Information:

Final Close-out 12/7/2020
Inspection Approval
Project Close-out NOT -Brook HollowDuplex.pdf 150.01KB
Approval Mast be FCFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Pnyperson 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 of the
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
A&k PN
Type Name* Hunter Blount
Title * Owner
Organization* E H Blount Construction
Date * 12/07/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 252.758.1081
NOT Certification CCF_001090.pdf 402.01 KB
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Notification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]