NCC201571_Notice of Termination_20210609

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/9/2021 4:50:03 PM (NOT Submittal)
Approve by Morman, Alaina 6/10/2021 11:48:00 AM (NOT Request Review- NCC201571)
• The task was assigned to Morman, Alaina. The due date is: June 14, 2021 5:00 PM 6/9/2021 4:50 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201571
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
fvby be blank (if not yet billed).
Information associated with this permit:
Project Name
Langdon Farms Subdivision - Phase 2
Address
Shetland Lane, Smithfield Township, NC
County
Johnston
Latitude
35.4973
Longitude
-78.4504
Permittee Listed
James M. Gilbert, Inc.
Legally Responsible
James Gilbert
Individual
NC Reference No.
NCG01-2020-1571
E&SC Plan ID
JC #20-018-P
Original NOI
24510
Tracking No.
Date COC Issued
4/20/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
f Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
F Other The residential lots developed by the Permittee, noted above,
have been sold to three ( 3 ) Builders.

Add ional Mxe information about the basis of this request, if needed.
Explanation The three Builders have applied for and
received their Certificates of Coverage. The
Builders were issued the following COC
numbers: NCC212426, NCC212400 and
NCC212432.
Supporting Upload Supporting DDcurrentation if applicable.
Documentation Mast beFDFformt
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFformat
Approval
Documentation
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 any recording or monitoring device 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
JAW �' yiat
Type Name* James M. Gilbert
Title * President
Organization* James M. Gilbert, Inc.
Date * 06/09/2021
Email for [e-mail]
Confirmation *
Contact Telephone * 9199176279
NOT Certification Scan_0594.pdf 663.42KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?

Additional Email CCd on Notification Bmils
(Optional) [e-mail]
Original Permittee CCdonWificationBTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]