NCC201914_Notice of Termination_20210506

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/6/2021 2:57:54 PM (NOT Submittal)
Approve by Morman, Alaina 5/14/2021 4:21:58 PM (NOT Request Review- NCC201914)
• The task was assigned to Morman, Alaina. The due date is: May 11, 2021 5:00 PM 5/6/2021 2:58 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201914
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
162 Holly Springs Ct
Address
Holly Springs Ct, Sounthern Pines, NC
County
Moore
Latitude
35.1870
Longitude
-79.4200
Permittee Listed
McKee Homes, LLC
Legally Responsible
Kelsey Rivera
Individual
NC Reference No.
NCG01-2020-1914
E&SC Plan ID
20-1236
Original NOI
25261
Tracking No.
Date COC Issued
5/11/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 Nbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation NtastbeRYforrrat

Project Close-out Information:
Final Close-out 11/13/2020
Inspection Approval
Project Close-out 162 Holly Signed ESC Completion Letter.docx.pdf 43.35KB
Approval Must be FDFfornat
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 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 Artcle 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* Kelsey Rivera
Title * Pre Construction Coordinator
Organization* McKee Homes, LLC
Date * 05/06/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9104757100
NOT Certification 162 HolIyNCG01-eNOT-Certification-Form-
Form 20210305-DEMLR-SW 2.pdf
Mist be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification En -ails
(Optional)
Original Permittee CCd on Wtification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
876.79KB