NCC201655_Notice of Termination_20210315

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/15/2021 12:21:59 AM (NOT Submittal)
Approve by Morman, Alaina 3/15/2021 5:10:16 PM (NOT Request Review- NCC201655)
• The task was assigned to Morman, Alaina. The due date is: March 18, 2021 5:00 PM
3/15/2021 12:22 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201655
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
Carlton Pointe S/D Phase 3, Lot 131
Address
732 Strathwood Way, Rolesville, NC
County
Wake
Latitude
35.9050
Longitude
-78.4740
Permittee Listed
Brandywine Homes, Inc.
Legally Responsible
Colleen Cunningham
Individual
NC Reference No.
NCG01-2020-1655
E&SC Plan ID
SEC-036291-2020
Original NOI
24714
Tracking No.
Date COC Issued
4/27/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 12/21/2020
Inspection Approval
Project Close-out sec-036291-
Approval 2020_SR_Erosion_Control_Certificate_of Comple... 48.27KB
Documentation
12-2020_10-15-45. pdf
Mast be FDFforrrat
North Carolina General Statute 143-215.613 (i) 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 Artide or a rule implementing this A tide; 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 device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 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* Colleen M Cunningham
Title * President
Organization* Brandywine Homes, Inc.
Date * 03/15/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9195543351
NOT Certification NCG01-eNOT-Certification-Form-20210305-
Form 976.67KB
DEMLR-SW cp131.pdf
Mast be FDF Format
Is this COC Already Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Bmils
[e-mail]
CCd on Notification Errails
[e-mail]

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