NCC202235_Notice of Termination_20210510

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/10/2021 4:58:39 PM (NOT Submittal)
Approve by Morman, Alaina 5/17/2021 9:41:43 AM (NOT Request Review- NCC202235)
• The task was assigned to Morman, Alaina. The due date is: May 13, 2021 5:00 PM 5/10/2021 4:58 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC202235
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
fvby be blank (if not yet billed).
Information associated with this permit:
Project Name
Taberna
Address
Calvary Drive, Greenville, NC
County
Pitt
Latitude
35.5571
Longitude
-77.4465
Permittee Listed
ROCKY RUSSELL BUILDERS, INC.
Legally Responsible
ROCKY RUSSELL
Individual
NC Reference No.
NCG01-2020-2235
E&SC Plan ID
ESCP-2020-0032
Original NOI
26227
Tracking No.
Date COC Issued
5/28/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
r Mistake or Invalid Coverage
r Other
Addional Nbre information about the basis of this request, if needed.
Explanation I HAVE SOLD ALL LOTS I OWN IN
SUBDIVISION.

Supporting Upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 5/10/2021
Inspection Approval
Project Close-out NOT-Taberna Rocky Russell.pdf
Approval Mast be FDFformat
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
149.48KB
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Artide 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 device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 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* Rocky Russell
Title * President
Organization* Rocky Russell Builders, Inc.
Date * 05/10/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 2523412301
NOT Certification 20210510170827406.pdf 61.83KB
Form Mast be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification BTails
(Optional)
Original Permittee CCd on Notification Errails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]