NCC202497_Notice of Termination_20210607

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/7/2021 8:10:40 AM (NOT Submittal)
Approve by Morman, Alaina 6/9/2021 3:33:33 PM (NOT Request Review- NCC202497)
• The task was assigned to Morman, Alaina. The due date is: June 10, 2021 5:00 PM 6/7/2021 8:10 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202497
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
Blakefield Subdivision, Phase 6 Lots 3, 4 & 22-24
Address
Croft Drive, Cedar Creek Township, NC
County
Cumberland
Latitude
35.0308
Longitude
-78.7638
Permittee Listed
JW Sealey & Associates, Inc.
Legally Responsible
Theodore Sealey
Individual
NC Reference No.
NCG01-2020-2497
E&SC Plan ID
CUMBE-2020-187
Original NOI
26986
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Cate populates only if COCwas already rescinded at time of submittal.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 4/8/2021
Inspection Approval
Project Close-out Blakefield close out.pdf
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
78.31 KB
Any person who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
document filed 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 under this Article; or who falsifies, tampers with, or knowinglyrenders
inaccurate any recording 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 may include 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
T&4& C. 1"
Type Name* Theodore C Sealey
Title * President
Organization * JW Sealey and Associates, Inc
Date * 06/07/2021
Email for [e-mail]
Confirmation *
Contact Telephone * [e-mail]
NOT Certification NOT Cert.pdf 393.79KB
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 Errails
CCd on Notification Bmils
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]