NCC201935_Notice of Termination_20210517

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/17/2021 3:47:04 PM (NOT Submittal)
Approve by Morman, Alaina 5/23/2021 11:13:54 AM (NOT Request Review- NCC201935)
• The task was assigned to Morman, Alaina. The due date is: May 20, 2021 5:00 PM 5/17/2021 3:47 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201935
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 Lot 5 Barham Reserve
Address 6936 Will Let Ln, Wake Forest, NC
County Wake
Latitude 36.0000
Longitude-78.0000
Permittee Listed Winslow Custom Homes, LLC
Legally Responsible Matthew Winslow
Individual
NC Reference No. NCG01-2020-1935
E&SC Plan ID SEC-035965-2020
Original NOI 25368
Tracking No.
Date COC Issued 5/12/2020
Prior Rescission Cate populates only if COCwas already rescinded at time of submittal.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 5/12/2021
Inspection Approval
Project Close-out SEC-035965-2020_Certificate of Completion_4-30-
Approval 21.pdf 163.42KB
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
r_14111«r �i e
Type Name* Adam Moon
Title * Construction Manager
Organization * Winslow Homes
Date * 05/17/2021
Email for amoon@winslo\Nhomes.com
Confirmation *
Contact Telephone* 9194822920
NOT Certification 20210517144519 Not Form.pdf
Form Mast be PDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCd onNotificationBmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
61.58KB