NCC201168_Notice of Termination_20210511

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/11/2021 10:51:10 AM (NOT Submittal)
Approve by Morman, Alaina 5/17/2021 2:17:27 PM (NOT Request Review- NCC201168)
• The task was assigned to Morman, Alaina. The due date is: May 14, 2021 5:00 PM
5/11/2021 10:51 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201168
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
K/hy be blank (if not yet billed).
Information associated
with this permit:
Project Name
Wendell Falls Phase 8A Lots 1041-1066
Address
296 Douglas Falls Drive, Wendell, NC
County
Wake
Latitude
35.7750
Longitude
-78.4307
Permittee Listed
Dan Ryan Builders
Legally Responsible
Jay Lewis
Individual
NC Reference No.
NCG01-2020-1168
E&SC Plan ID
SEC-031079-2020
Original NOI
23337
Tracking No.
Date COC Issued
4/15/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation MstbeRYforrrat

Project Close-out Information:
Final Close-out 2/21/2021
Inspection Approval
Project Close-out SEC-031079-2020_Certificate of Completion_ 2-12-
Approval 21.pdf 134.53KB
Documentation
Mast be FDFforrrat
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* Jay Lewis
Title * Division President
Organization* Dan Ryan Builders
Date * 05/11 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 919-478-8149
NOT Certification NCG01-eNOT-Certification-Form-Signed.pdf
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
22.65KB