NCC192296_Notice of Termination_20201230

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/30/2020 11:13:29 AM (NOT Submittal)
Approve by Georgoulias, Bethany 1/4/2021 2:07:09 PM (NOT Request Review- NCC192296)
• The task was assigned to Georgoulias, Bethany. The due date is: January 4, 2021 5:00 PM
12/30/2020 11:13 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC192296
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Chapel Ridge Lot 185
Address
343 High Ridge Lane, Pittsboro, NC
County
Chatham
Latitude
35.7880
Longitude
-79.2149
Permittee Listed
20/20 SITE DEVELOPMENT CO., INC.
Legally Responsible
THOMAS SIEMIENIK
Individual
NC Reference No.
NCG01-2019-2296
E&SC Plan ID
2019-08027
Original NOI
17006
Tracking No.
Date COC Issued
10/11/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 12/29/2020
Inspection Approval
Project Close-out Notice of termination ( CR 131 185 ).pdf 691.35KB
Approval Mast be FDFforrrat
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).
rJ 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
�r•�xt.�a5i�ar��
Type Name* Thomas Richard Siemienik
Title * President
Organization* 20/20 Site Development Company, Inc.
Date * 12/30/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-338-4072
NOT Certification Notice of termination ( CR 131 185 ).pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
691.35KB