NCC200144_Notice of Termination_20210222

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/22/2021 4:48:19 PM (NOT Submittal)
Approve by Morman, Alaina 2/23/2021 5:14:52 PM (NOT Request Review- NCC200144)
• The task was assigned to Morman, Alaina. The due date is: February 25, 2021 5:00 PM
2/22/2021 4:48 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200144
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
PAST DUE
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Billet's Run Lot 2
Address
179 Billet's Run, Moncure, NC
County
Chatham
Latitude
35.6275
Longitude
-79.0647
Permittee Listed
Hearthstone Luxury Homes
Legally Responsible
Jeff Logsdon
Individual
NC Reference No.
NCG01-2020-0144
E&SC Plan ID
2020-00071
Original NOI
20452
Tracking No.
Date COC Issued
1/14/2020
Prior Rescission
Clete populates only if COCwas already rescinded at time of submittal.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 Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation NlastbeRYforrrat

Project Close-out Information:
Final Close-out 1/7/2021
Inspection Approval
Project Close-out 19179-CERTIFICATE OF COMPLETION Stormwater
Approval 209.25KB
Permit —Billets Run Lot 2.pdf
Documentation
Mist be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes any false 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 knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; or who 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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to 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 Logsdon
Title * President / Owner
Organization* Hearthstone Luxury Homes
Date * 02/22/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7039656917
NOT Certification NCG01 Notice of Termination (NOT) Certification
Form Form.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Firnils
Email [e-mail]
392.17KB