NCC201598_Notice of Termination_20210405

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/5/2021 11:01:17 AM (NOT Submittal)
Approve by Morman, Alaina 4/6/2021 4:03:39 PM (NOT Request Review- NCC201598)
• The task was assigned to Morman, Alaina. The due date is: April 8, 2021 5:00 PM 4/5/2021 11:01 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201598
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
174 Holly Springs Ct
Address
Holly Springs, Southern Pines, NC
County
Moore
Latitude
35.1870
Longitude
-79.4200
Permittee Listed
McKee Homes, LLC
Legally Responsible
Kelsey Rivera
Individual
NC Reference No.
NCG01-2020-1598
E&SC Plan ID
20-1083
Original NOI
24513
Tracking No.
Date COC Issued
4/21/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation NtastbeRYforrrat

Project Close-out Information:
Final Close-out 11/13/2020
Inspection Approval
Project Close-out ESC Completion Letter Signed.docx.pdf 50.45KB
Approval NCC201598_Annual Fee Invoice_20210401.pdf 742.58KB
Documentation
Mast be FCFforrrat
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
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 174 Holly'.pdf
Form Mast be Ft7F 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]
120.27KB