NCC201595_Notice of Termination_20210412

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/12/2021 8:29:22 PM (NOT Submittal)
Approve by Morman, Alaina 4/13/2021 12:45:00 PM (NOT Request Review- NCC201595)
• The task was assigned to Morman, Alaina. The due date is: April 15, 2021 5:00 PM
4/12/2021 8:29 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201595
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
Nby be blank (if not yet billed).
Information associated
with this permit:
Project Name
RBPR-032316-2020, Lot 57 Savannah Oaks PH2
Address
8605 Flannery Court, Knightdale, NC
County
Wake
Latitude
35.8328
Longitude
-78.4665
Permittee Listed
matt baldwin homes, LLC
Legally Responsible
Matt Baldwin
Individual
NC Reference No.
NCG01-2020-1595
E&SC Plan ID
SEC-032322-2020
Original NOI
24598
Tracking No.
Date COC Issued
4/27/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 4/12/2021
Inspection Approval
Project Close-out SEC-032322-
Approval 632.59KB
2020_SR Erosion_Control_Certificate_of Comple...
Documentation
Mist 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 of the
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* Matt Baldwin
Title * Manager
Organization* matt baldwin homes, LLC
Date * 04/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9196330687
NOT Certification NCG01-eNOT-Certification-Form-20201215-
Form DEMLR-SW 57SVO.pdf
Mist be FDF Fbrrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
848.37KB