NCC204136_Notice of Termination_20210111

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/11/2021 10:31:12 AM (NOT Submittal)
Approve by Morman, Alaina 1/12/2021 2:44:22 PM (NOT Request Review- NCC204136)
• The task was assigned to Morman, Alaina. The due date is: January 14, 2021 5:00 PM
1/11/2021 10:31 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC204136
Coverage (COC)
Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
527 W Tremont
Address
527 W Tremont Avenue, Charlotte, NC
County
Mecklenburg
Latitude
35.2117
Longitude
-80.8695
Permittee Listed
Toll Brothers, Inc.
Legally Responsible
Dan Rossi
Individual
NC Reference No.
NCG01-2020-4136
E&SC Plan ID
LDGP-2020-00176
Original NOI
31607
Tracking No.
Date COC Issued
9/23/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
F Mistake or Invalid Coverage
r Other
Ad d io n a I We inforrration about the basis of this request, if needed.
Explanation Changed the Legally Responsible Entity
Name
Supporting upload Supporting Dccurrentation if applicable.
Documentation Mast beFDFforrrat

Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFforrrat
Approval
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
Type Name* Dan Rossi
Title * Vice President
Organization* Toll Brothers, Inc.
Date * 01 /11 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7044309392
NOT Certification 527 W Tremont NOT 1.11.21.pdf
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
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