NCC202394_Notice of Termination_20210429

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/29/2021 11:09:32 AM (NOT Submittal)
Approve by Morman, Alaina 4/30/2021 4:13:08 PM (NOT Request Review- NCC202394)
• The task was assigned to Morman, Alaina. The due date is: May 4, 2021 5:00 PM 4/29/2021 11:09 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202394
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
15 Middlebury
Address
15 Middlebury, pinehurst, NC
County
Moore
Latitude
35.2363
Longitude
-79.4316
Permittee Listed
Jacob Kirby
Legally Responsible
Jacob Kirby
Individual
NC Reference No.
NCG01-2020-2394
E&SC Plan ID
20-1374
Original NOI
26625
Tracking No.
Date COC Issued
6/12/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 4/29/2021
Inspection Approval
Project Close-out Signed ESC Completion Letter - jacob.pdf 50.62KB
Approval Mist 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
Type Name* matthew kirby
Title * member
Organization * Kirby Construction Group
Date * 04/29/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9106922731
NOT Certification NCG01 Notice of Termination (NOT) Certification
Form Form.pdf
Mist be FDF Format
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]
515.06KB