NCC200930_Notice of Termination_20210315

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/15/2021 11:53:54 AM (NOT Submittal)
Approve by Morman, Alaina 3/16/2021 1:30:51 PM (NOT Request Review- NCC200930)
• The task was assigned to Morman, Alaina. The due date is: March 18, 2021 5:00 PM
3/15/2021 11:54 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200930
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
K/hy be blank (if not yet billed).
Information associated with this permit:
Project Name
142 Margaret Manns Way - Manns Crossing Lot 24
Address
142 Margaret Manns Way, Pittsboro, NC
County
Chatham
Latitude
35.8320
Longitude
-79.1460
Permittee Listed
J Fuller Homes
Legally Responsible
Jim Anderson
Individual
NC Reference No.
NCG01-2020-0930
E&SC Plan ID
2020-00832
Original NOI
22820
Tracking No.
Date COC Issued
3/11/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.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 IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation MstbeRYforrrat

Project Close-out Information:
Final Close-out 3/15/2021
Inspection Approval
Project Close-out CERTIFICATE OF COMPLETION_Manns Crossing
Approval 390.57KB
Lot 24.pdf
Documentation
Mist be FDFforrrat
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 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
r/cam d'W,
Type Name* Jim Anderson
Title * President
Organization* J. Fuller Homes, LLC.
Date * 03/15/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 5853709276
NOT Certification NCG01-eNOT-Certification-Form-20201215-
Form DEMLR-SW[43].pdf
Mist be FDF Fornat
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 BTails
Email [e-mail]
1MB