NCC202268_Notice of Termination_20210702

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/2/2021 11:04:29 AM (NOT Submittal)
Approve by Morman, Alaina 7/7/2021 12:17:42 PM (NOT Request Review- NCC202268)
• The task was assigned to Morman, Alaina. The due date is: July 7, 2021 5:00 PM 7/2/2021 11:04 AM

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NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202268
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Orchard Meadows Lot 10
Address
2808 Orchard Meadows Ct., Raleigh, NC
County
Wake
Latitude
36.0000
Longitude
-79.0000
Permittee Listed
Cypress Homes Inc.
Legally Responsible
Russell Hart
Individual
NC Reference No.
NCG01-2020-2268
E&SC Plan ID
SEC-036911-2020
Original NOI
26256
Tracking No.
Date COC Issued
6/1/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
r Mistake or Invalid Coverage
r Other

Add ional We information about the basis of this request, if needed.
Explanation Both Lots completed in accordance with
documentation(Cert. of Completion) attached
- Lot #10 Orchard Meadows
- Lot #05 Orchard Meadows
Supporting Upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out
6/23/2021
Inspection Approval
Project Close-out
Certificate of Completion Orchard Meadows Lot 10
Approval
(062121).pdf
Documentation
Certificate of Completion Orchard Meadows Lot 5
(061421).pdf
NUst be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
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Any person who knowingly makes anyfalse statement, representation, or certification in any application, 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 knowingly renders
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 guilty ofa 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
Type Name* Russell Hart
Title * President
Organization* Cypress Homes Inc.
Date * 07/02/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9197626556

NOT Certification NCG01-eNOT-Certification-Form-20210514-
Form DEMLR-SW (NCC202268).pdf
Mast be PDF Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email OCd on Notification Errails
(Optional)
Original Permittee 0Cd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Ermils
Email [e-mail]
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