NCC191082_Notice of Termination_20201218

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/18/2020 2:10:19 PM (NOT Submittal)
Approve by Georgoulias, Bethany 1/8/2021 10:41:33 AM (NOT Request Review- NCC191082)
p A copy of the signed NOT Certification form was provided via e-mail on 1212112020. Mecklenburg
County provided final inspection documentation via e-mail on 11812021. The annual fee has been waived,
and the NOD is resolved.
• The task was assigned to Georgoulias, Bethany. The due date is: December 23, 2020 5:00 PM
12/18/2020 2:10 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191082
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status WAIVED
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Lot 2 Tartan Farm (#398550)
Address
248 Grey Rd, Davidson, NC
County
Mecklenburg
Latitude
35.4959
Longitude
-80.8341
Permittee Listed
CMR Builder Inc
Legally Responsible
Craig Roseman
Individual
NC Reference No.
NCG01-2019-1082
E&SC Plan ID
#398550
Original NOI
13978
Tracking No.
Date COC Issued
7/26/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
O 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 8/12/2020
Inspection Approval
Project Close-out WebPermit 7.3 - Building Requests Detail (public
Approval 99.79KB
view).pdf
Documentation
Mast be Ft7Fforrrat
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
Type Name* Craig M Roseman
Title * Owner/President/CEO
Organization* 43
Date * 12/18/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 7048960773
NOT Certification NOT.pdf
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]
142.73KB