NCC200627_Notice of Termination_20210210

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/10/2021 8:56:31 AM (NOT Submittal)
Approve by Morman, Alaina 2/11/2021 5:06:57 PM (NOT Request Review- NCC200627)
• The task was assigned to Morman, Alaina. The due date is: February 15, 2021 5:00 PM
2/10/2021 8:56 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200627
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
Nhy be blank (if not yet billed).
Information associated with this permit:
Project Name
Chatham Park DWRRF Potable Water Line Extension
Address
US Highway 64 Business, Pittsboro, NC
County
Chatham
Latitude
35.7197
Longitude
-79.1363
Permittee Listed
Chatham Park Investors LLC
Legally Responsible
Tim Smith
Individual
NC Reference No.
NCG01-2020-0627
E&SC Plan ID
2018-06290
Original NOI
21897
Tracking No.
Date COC Issued
2/18/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 2021.02.05 CERTIFICATE OF COMPLETION.pdf 34.35KB
Approval Must 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
Type Name* Robin R. Rose
Title * Designated Agent
Organization* Chatham Park Investors LLC
Date * 02/10/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9194813000
NOT Certification 2021.02.09 DWRRF Water Line Ext. eNOT
Form Certification signed.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email OCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]
98.07KB