NCC205264_Notice of Termination_20210212

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/12/2021 11:03:18 AM (NOT Submittal)
Approve by Morman, Alaina 2/15/2021 11:36:31 AM (NOT Request Review- NCC205264)
• The task was assigned to Morman, Alaina. The due date is: February 17, 2021 5:00 PM
2/12/2021 11:03 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC205264
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
Legend Oaks
Address
Legend Oaks Drive, Williams, NC
County
Chatham
Latitude
35.8412
Longitude
-79.0715
Permittee Listed
Robuck Homes Triangle, LLC
Legally Responsible
Jessica Head
Individual
NC Reference No.
NCG01-2020-5264
E&SC Plan ID
2019-07551
Original NOI
36100
Tracking No.
Date COC Issued
11/18/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
F Mistake or Invalid Coverage
r Other
Addional We inforrration about the basis of this request, if needed.
Explanation duplicate coverage

Supporting Upload Supporting Documentation if applicable.
Documentation 263 Legend Oaks Dr. - parcel 0087028 - NC GO1 -
729.3KB
LO invoice.pdf
NUst be FDFformat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFforrrat
Approval
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).
I7 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* Jai Norbech
Title * Process and Systems Manager
Organization * Robuck Homes Triangle, LLC
Date * 02/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9197104931
NOT Certification NCC205264.pdf 1.76MB
Form Mast be FDF Fornat
Is this COC Already Ensure this COChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)

Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]