NCC205589_Notice of Termination_20210603

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/3/2021 8:18:30 AM (NOT Submittal)
Approve by Morman, Alaina 6/9/2021 11:11:05 AM (NOT Request Review- NCC205589)
• The task was assigned to Morman, Alaina. The due date is: June 8, 2021 5:00 PM 6/3/2021 8:18 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC205589
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Creekwood Farms - Lot 16
Address
Creekwood Road, Grays Creek, NC
County
Cumberland
Latitude
34.8848
Longitude
-78.9226
Permittee Listed
Caviness Land Development, Inc
Legally Responsible
Watson Caviness
Individual
NC Reference No.
NCG01-2020-5589
E&SC Plan ID
CUMBE-2021-056
Original NOI
38054
Tracking No.
Date COC Issued
12/7/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 5/26/2021
Inspection Approval
Project Close-out Close out inspection 5.26.21.pdf 24.72KB
Approval Mast be FDFforrrat
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 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
+j��rl�at�r. ��`�rrr�sr�lrl
Type Name* Watson G Caviness
Title * President
Organization* Caviness Land Development
Date * 06/03/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9193396330
NOT Certification NOT cert form.pdf 264.84KB
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Erails
CCd on Notification Erails
[e-mail]
Original Site Contact OCd on Notificaiton Errails
Email [e-mail]