NCC202516_Notice of Termination_20210602

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/2/2021 3:00:04 PM (NOT Submittal)
Approve by Morman, Alaina 6/7/2021 5:30:47 PM (NOT Request Review- NCC202516)
• The task was assigned to Morman, Alaina. The due date is: June 7, 2021 5:00 PM 6/2/2021 3:00 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC202516
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
Mary Susan Baggett and Lee Roy Baggett Subdivision - Lots 3 & 4
Address
Saraya Drive SR-2840, Eastover Township, NC
County
Cumberland
Latitude
35.0926
Longitude
-78.7891
Permittee Listed
JW Sealey & Associates
Legally Responsible
Theodore Sealey
Individual
NC Reference No.
NCG01-2020-2516
E&SC Plan ID
CUMBE-2020-188
Original NOI
26991
Tracking No.
Date COC Issued
6/16/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 6/2/2021
Inspection Approval
Project Close-out Mary Susan Baggett & Lee Roy Baggett Subdivision
Approval 37.94KB
- Lots 3 &4.pdf
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 device 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 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
)WA4 C. I
Type Name* Theodore Sealey
Title * president
Organization * JW Sealey and Associates, Inc
Date * 06/02/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9108974210
NOT Certification NOT Cert2.pdf 399.95KB
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Erails
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]