NCC200865_Notice of Termination_20210301

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/1/2021 11:58:03 AM (NOT Submittal)
Approve by Morman, Alaina 3/2/2021 9:38:39 PM (NOT Request Review- NCC200865)
• The task was assigned to Morman, Alaina. The due date is: March 4, 2021 5:00 PM
3/1/2021 11:58 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200865
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
PAPILLON PARK LOT 16
Address
2260 DUSKYWING DRIVE, RALEIGH, NC
County
Wake
Latitude
35.9622
Longitude
-78.7118
Permittee Listed
WARDSON CONSTRUCTION INC
Legally Responsible
BENJAMIN WARD
Individual
NC Reference No.
NCG01-2020-0865
E&SC Plan ID
SEC-33529-2020
Original NOI
22730
Tracking No.
Date COC Issued
3/4/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Addional Nbre information about the basis of this request, if needed.
Explanation CERTIFICATE OF COMPLETION -
SEDIMENTATION AND EROSION CONTROL
ISSUED 10/28/20, PROJECT COMPLETED
AND HOME SOLD ON 1/15/21

Supporting Upload Supporting Ebcurrentation if applicable.
Documentation Mist bePIDFforrrat
Project Close-out Information:
Final Close-out 10/28/2020
Inspection Approval
Project Close-out 16 PAPILLON PARK S&EC CERTIFICATE OF
Approval COMPLETION.pdf
Documentation
Mast be Ft7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
88.37KB
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* BENJAMIN K. WARD
Title * PRESIDENT
Organization* WARDSON CONSTRUCTION INC
Date * 03/01 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9194620775
NOT Certification 20210301121836594.pdf 92.42KB
Form Mast be PIDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonWtificationBails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]