NCC201462_Notice of Termination_20210405

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/5/2021 11:03:33 AM (NOT Submittal)
Approve by Morman, Alaina 4/6/2021 3:56:35 PM (NOT Request Review- NCC201462)
• The task was assigned to Morman, Alaina. The due date is: April 8, 2021 5:00 PM 4/5/2021 11:03 AM

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NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201462
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
116 Plantation Drive
Address
Plantation Drive, Southern Pines, NC
County
Moore
Latitude
35.1880
Longitude
-79.4143
Permittee Listed
McKee Homes, LLC
Legally Responsible
Kelsey Rivera
Individual
NC Reference No.
NCG01-2020-1462
E&SC Plan ID
20-1068
Original NOI
24155
Tracking No.
Date COC Issued
4/13/2020
Prior Rescission
Clete populates only if COCwas already rescinded at time of submittal.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 9/15/2020
Inspection Approval
Project Close-out 116ESC Completion Letter Signed.docx.pdf 52.21 KB
Approval NCC201462_Annual Fee Invoice_20210401.pdf 741.93KB
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed 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 under this 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 may include 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
Type Name* Kelsey Rivera
Title * Pre Construction Coordinator
Organization* McKee Homes, LLC
Date * 04/05/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9104757100
NOT Certification 116 Plantation.pdf
Form Mast be PDF 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 Errails
Email [e-mail]
119.89KB