NCC201605_Notice of Termination_20210401

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/1/2021 10:45:21 AM (NOT Submittal)
Approve by Morman, Alaina 4/6/2021 3:03:58 PM (NOT Request Review- NCC201605)
p Belmeade Single Family is covered by COC number NCC202848.
• The task was assigned to Morman, Alaina. The due date is: April 6, 2021 5:00 PM 4/1/2021 10:45 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201605
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
Belmeade Single Family
Address
2633 BelmeadeDrive, Charlotte, NC
County
Mecklenburg
Latitude
35.0000
Longitude
-81.0000
Permittee Listed
Adams Contracting Co. Inc.
Legally Responsible
Rance Adams
Individual
NC Reference No.
NCG01-2020-1605
E&SC Plan ID
LDGP-2020-00070
Original NOI
24575
Tracking No.
Date COC Issued
4/23/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
f Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other We were actually never even awarded this project
Addional Nbre inforrration about the basis of this request, if needed.
Explanation We were actually never even awarded this
project, we got this permit but we ended up
not getting the job.

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mast beFDFforrrat
Approval
Documentation
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 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 device or method required to be operated or maintained under this Article 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* Rance Adams
Title * President
Organization* Adams Contracting Co. Inc.
Date * 04/01 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 828-479-4626
NOT Certification NOT Form for COC No. NCC201605.pdf
Form Mast be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Brails
(Optional)
Original Permittee CCd on Notification Brails
Email [e-mail]
30.68KB

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