NCC204727_Notice of Termination_20210420

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/20/2021 3:55:02 PM (NOT Submittal)
Approve by Morman, Alaina 4/22/2021 4:31:34 PM (NOT Request Review- NCC204727)
• The task was assigned to Morman, Alaina. The due date is: April 23, 2021 5:00 PM
4/20/2021 3:55 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC204727
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Forest Oaks Phase 5 - Lots 263, 315, 316 & 317
Address
Silk Oak Dr, Anderson Creek Township, NC
County
Harnett
Latitude
35.0000
Longitude
-79.0000
Permittee Listed
Caviness Land Development, Inc
Legally Responsible
Watson Caviness
Individual
NC Reference No.
NCG01-2020-4727
E&SC Plan ID
HARNE-2021-056
Original NOI
33278
Tracking No.
Date COC Issued
10/21/2020
Prior Rescission
Date populates only if OOC was already rescinded at tirre of submittal.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 *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 4/7/2021
Inspection Approval
Project Close-out Close out report 4.7.21.pdf 32.66KB
Approval Mast be FDFforrrat
Documentation
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
+j��rl�at�r. ��`�rrr�sr�lrl
Type Name* Watson G Caviness
Title * President
Organization* Caviness Land Development
Date * 04/20/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9193396330
NOT Certification NOT cert form.pdf 275.87KB
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Erails
CCd on Notification Erails
[e-mail]
Original Site Contact OCd on Notificaiton Errails
Email [e-mail]