NCC200784_Notice of Termination_20210205

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/5/2021 12:39:26 PM (NOT Submittal)
Approve by Morman, Alaina 2/8/2021 12:06:28 PM (NOT Request Review- NCC200784)
• The task was assigned to Morman, Alaina. The due date is: February 10, 2021 5:00 PM
2/5/2021 12:39 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200784
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
N/hy be blank (if not yet billed).
Information associated
with this permit:
Project Name
Seaforth Landing Lot 18
Address
516 Seaforth Landing Drive, Pittsboro, NC
County
Chatham
Latitude
35.7120
Longitude
-79.0660
Permittee Listed
Poythress Construction Company Inc
Legally Responsible
Kevin Poythress
Individual
NC Reference No.
NCG01-2020-0784
E&SC Plan ID
2020-01348
Original NOI
22460
Tracking No.
Date COC Issued
2/28/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
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 *
r Mistake or Invalid Coverage
r Other
Addional IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation MstbeRYforrrat

Project Close-out Information:
Final Close-out 2/5/2021
Inspection Approval
Project Close-out CERTIFICATE OF COMPLETION.pdf 34.39KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 notto 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
4 "fAry
Type Name* Nolan Poythress
Title * VP
Organization* Poythress Construction Company
Date * 02/05/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9198106087
NOT Certification NOT Lot 18 Seaforth.pdf 278.3KB
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
CCd on Notification Bmils
[e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]