NCC201214_Notice of Termination_20210512

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/12/2021 1:12:07 PM (NOT Submittal)
Approve by Morman, Alaina 5/17/2021 4:09:24 PM (NOT Request Review- NCC201214)
• The task was assigned to Morman, Alaina. The due date is: May 17, 2021 5:00 PM 5/12/2021 1:12 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201214
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
PAID
Nt3y be blank (if not yet billed).
Information associated
with this permit:
Project Name
Camberly Lot 67
Address
7545 Dover Hills Drive, Wake Forest, NC
County
Wake
Latitude
35.9875
Longitude
-78.5729
Permittee Listed
Herring Homes
Legally Responsible
Brian Herring
Individual
NC Reference No.
NCG01-2020-1214
E&SC Plan ID
SEC-033256-2020
Original NOI
23446
Tracking No.
Date COC Issued
3/26/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 Mist beRYforrrat

Project Close-out Information:
Final Close-out 5/5/2021
Inspection Approval
Project Close-out SEC-033256-2020-Certificate of Completion.pdf 137.15KB
Approval Mast 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 Amide; 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
czt.�rl [:rrtdrrr�ci�oo�c
Type Name* Nataleigh Carscaddon
Title * Permits Coordinator
Organization* Herring Realty LLC
Date * 05/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9192689127
NOT Certification CAM 67 Notice of Termination to State.pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email OCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
34.01 KB