NCC201967_Notice of Termination_20210503

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/3/2021 1:09:33 PM (NOT Submittal)
Approve by Georgoulias, Bethany A 5/4/2021 10:00:47 AM (NOT Request Review- NCC201967)
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 5/4/2021 9:54 AM
The task was assigned to Morman, Alaina. The due date is: May 6, 2021 5:00 PM 5/3/2021 1:09 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201967
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
Chapel Ridge Lot 548
Address
802 Cabin Creek, Pittsboro, NC
County
Chatham
Latitude
36.0000
Longitude
-79.0000
Permittee Listed
Triple A Homes
Legally Responsible
Gerry Felton
Individual
NC Reference No.
NCG01-2020-1967
E&SC Plan ID
2020-03066
Original NOI
25474
Tracking No.
Date COC Issued
5/13/2020
Prior Rescission
Date populates only if COCwas already rescinded at time of submittal.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 5/3/2021
Inspection Approval
Project Close-out CR 548 CERTIFICATE OF COMPLETION.pdf 140.09KB
Approval Must be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 mayinclude a fine notto 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* Gerry Felton
Title * VP
Organization * Triple A Homes
Date * 05/03/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9498120991
NOT Certification CR 548 NCG01-eNOTermination-Certification-Form-
Form 334.95KB
20190508-DEMLR-SW. pdf
Mist be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Er ails
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]