NCC200830_Notice of Termination_20210205

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/5/2021 12:36:39 PM (NOT Submittal)
Approve by Morman, Alaina 2/8/2021 12:08:53 PM (NOT Request Review- NCC200830)
• The task was assigned to Morman, Alaina. The due date is: February 10, 2021 5:00 PM
2/5/2021 12:36 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200830
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
Seaforth Landing Lot 26
Address
240 Seaforth Landing Drive, Pittsboro, NC
County
Chatham
Latitude
35.7120
Longitude
-79.0640
Permittee Listed
Poythress Construction Company Inc
Legally Responsible
Kevin Poythress
Individual
NC Reference No.
NCG01-2020-0830
E&SC Plan ID
2020-01349
Original NOI
22461
Tracking No.
Date COC Issued
3/3/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
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 2/5/2021
Inspection Approval
Project Close-out CERTIFICATE OF COMPLETION - Lot 26.pdf 32.74KB
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 anyrecording 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
(27ILlif �wd'
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 26 Seaforth.pdf 274.21 KB
Form Mast be FDF Forrrat
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 CCd on Notificaiton Errails
Email [e-mail]