NCC191388_Notice of Termination_20210208

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/8/2021 9:47:24 PM (NOT Submittal)
Approve by Morman, Alaina 2/9/2021 4:15:56 PM (NOT Request Review- NCC191388)
p Annette Lucas and Suzanne McCoy assisted permittee. Close-out documentation and NOT are
acceptable.
• The task was assigned to Morman, Alaina. The due date is: February 11, 2021 5:00 PM
2/8/2021 9:47 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191388
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status PAST DUE
2021 Annual Fee Status Nbybeblank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Reviewstep) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Lakefront Ridge Subdivision
Address
Flint Ridge Road, Prospect Hill, NC, Hightowers, NC
County
Caswell
Latitude
36.3337
Longitude
-79.1597
Permittee Listed
Jeff Kirby and/or Frank Williams
Legally Responsible
Cynthia Kirby
Individual
NC Reference No.
NCG01-2019-1388
E&SC Plan ID
CASWE-2019-001
Original NOI
14869
Tracking No.
Date COC Issued
8/16/2019
Prior Rescission
Cate populates only if CDC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
C Project Closed -Out
Termination of
Q Sale (Another Owner/Operator will apply for a new COC)
Coverage *
a Mistake or Invalid Coverage
0 Other

Add ional Nbre information about the basis of this request, if needed.
Explanation Note: the Closeout report is hard to read but
it is bona fide.
Supporting Upload Supporting Documentation if applicable.
Documentation Mist beFCFforrrat
Project Close-out Information:
Final Close-out 4/17/2020
Inspection Approval
Project Close-out Kirby Closeout.pdf 228.17KB
Approval Mist be FDFfornat
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 ofthe
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
Type Name* Jeff Kirby
Title * Owner
Organization* Lakefront Ridge Subdivision
Date * 02/08/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-516-1239
NOT Certification Kirby NOT certification form.pdf 545.7KB
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification BTails
(Optional) [e-mail]

Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact GCd on Notificaiton Blails
Email [e-mail]