NCC204420_Notice of Termination_20210506

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/6/2021 1:18:35 PM (NOT Submittal)
Approve by Georgoulias, Bethany A 5/7/2021 8:09:03 AM (NOT Request Review- NCC204420)
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 5/7/2021 8:08 AM
The task was assigned to Morman, Alaina. The due date is: May 11, 2021 5:00 PM 5/6/2021 1:18 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC204420
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
Gordon Park Subdivision Lots 70, 71, 75, 83, 84, 85, 86, 87, 88, 89
Address
Near intersection of Glen Laurel Road and Powhatan Road, Clayton, NC
County
Johnston
Latitude
35.6238
Longitude
-78.3990
Permittee Listed
Cates Building, Inc
Legally Responsible
Christopher E Cates
Individual
NC Reference No.
NCG01-2020-4420
E&SC Plan ID
JC#19-072-P
Original NOI
32456
Tracking No.
Date COC Issued
10/6/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 5/6/2021
Inspection Approval
Project Close-out GO70,71,75,83-89-closeout letter.pdf 382.85KB
Approval Mast 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 anyrecording 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 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* CHRISTOPHER E. CATES
Title * VICE PRESIDENT
Organization * Caviness & Cates Building and Development Company
Date * 05/06/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9107787902
NOT Certification GO70,71,75,83-89 NOT.pdf
Form Mast be FDF Forrrst
Is this COC Already Ensure this COChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
355.61 KB