NCC201120_Notice of Termination_20210315

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/15/2021 12:30:11 AM (NOT Submittal)
Approve by Morman, Alaina 3/15/2021 5:13:21 PM (NOT Request Review- NCC201120)
• The task was assigned to Morman, Alaina. The due date is: March 18, 2021 5:00 PM
3/15/2021 12:30 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201120
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
Stonewater S/D Phase 5, Lot 192
Address
616 Pelzer Drive, Wake Forest, NC
County
Wake
Latitude
35.9031
Longitude
-78.4972
Permittee Listed
Brandywine Homes, Inc.
Legally Responsible
Colleen Cunningham
Individual
NC Reference No.
NCG01-2020-1120
E&SC Plan ID
Stonewater S/D Phase 5, Lot 192
Original NOI
23251
Tracking No.
Date COC Issued
3/19/2020
Prior Rescission
Date populates only if COCwas already rescinded at time of submittal.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 obtained 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 11/30/2020
Inspection Approval
Project Close-out SEC-033611-2020_Certificate of Completion_11-30-
Approval 20.pdf 165.23KB
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
L .�O2�le rfN �/fl L lMlll.Y�lB/9Q"
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 977.45KB
DEMLR-SW sw192.pdf
Mist be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Erails
[e-mail]
Original Site Contact CCd on Notificaiton EiTails
Email [e-mail]