NCC202561_Notice of Termination_20210601

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/1/2021 1:31:50 PM (NOT Submittal)
Approve by Morman, Alaina 6/3/2021 1:10:52 PM (NOT Request Review- NCC202561)
• The task was assigned to Morman, Alaina. The due date is: June 4, 2021 5:00 PM 6/1/2021 1:31 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC202561
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
Nby be blank (if not yet billed).
Information associated with this permit:
Project Name
Stonewater S/D, Phase 5 Lot 176
Address
1245 Argentum Street, Wake Forest, NC
County
Wake
Latitude
35.9311
Longitude
-78.4974
Permittee Listed
Brandywine Homes, Inc.
Legally Responsible
Colleen Cunningham
Individual
NC Reference No.
NCG01-2020-2561
E&SC Plan ID
SEC-038224-2020
Original NOI
27031
Tracking No.
Date COC Issued
6/25/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 4/30/2021
Inspection Approval
Project Close-out SEC-038224-2020_Certificate of Completion_ 4-30-
Approval 21.pdf 134.47KB
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording or monitoring deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto 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
L .�O2�le rfN �/fl L lMlll.Y�lB/9Q"
Type Name* Colleen M Cunningham
Title * President
Organization* Brandywine Homes, Inc.
Date * 06/01 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9195543351
NOT Certification NCG01-eNOT-Certification-Form-20210514-
Form 1.05MB
DEMLR-SW SW176.pdf
Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
0Cd on Notification Errails
[e-mail]
0Cd on Notification Erails
[e-mail]
Original Site Contact 0Cd on Notificaiton BTails
Email [e-mail]