NCC201166_Notice of Termination_20210204

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/4/2021 1:33:44 PM (NOT Submittal)
Approve by Morman, Alaina 2/8/2021 10:19:36 AM (NOT Request Review- NCC201166)
• The task was assigned to Morman, Alaina. The due date is: February 9, 2021 5:00 PM
2/4/2021 1:33 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201166
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Harry & Dorothy Leete Minor Subdivision Lot 3
Address
7608 Mitchell Mill Road, Zebulon, NC
County
Wake
Latitude
35.8987
Longitude
-78.4081
Permittee Listed
Grande Manor Homes, LLC
Legally Responsible
Christopher Davis
Individual
NC Reference No.
NCG01-2020-1166
E&SC Plan ID
SEC-031095-2020
Original NOI
23330
Tracking No.
Date COC Issued
3/25/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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
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 1/20/2021
Inspection Approval
Project Close-out Lot 3 MMR - SEC-031095-2020 Certificate of
Approval 166.66KB
Completion 1-20-21.pdf
Documentation
Mist be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed 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 under this 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 guilty ofa Class 2 misdemeanor which may include 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* David D. Cyrus
Title * Manager
Organization* Grande Manor Homes, LLC
Date * 02/04/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 919-669-5933
NOT Certification Lot 3 MMR - NCG01 NOT Certification Form
Form 1.21.2021.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
117.49KB