NCC202409_Notice of Termination_20210728

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/28/2021 10:24:33 AM (NOT Submittal)
Approve by Morman, Alaina 7/29/2021 1:45:43 PM (NOT Request Review- NCC202409)
• The task was assigned to Morman, Alaina. The due date is: August 2, 2021 5:00 PM
7/28/2021 10:25 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC202409
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
Nby be blank (iF not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Review step) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Avalaire lot 32
Address
5133 Avalaire Oaks Drive, Bartons Creek, NC
County
Wake
Latitude
35.9189
Longitude
-78.6246
Permittee Listed
Robuck Design Build LLC
Legally Responsible
Gerri Herakovich
Individual
NC Reference No.
NCG01-2020-2409
E&SC Plan ID
SEC-038180-2020 Avalaire lot 32
Original NOI
26699
Tracking No.
Date COC Issued
6/11/2020
Prior Rescission
Cate populates only ff OOCwas already rescinded at tirre of subaittal.
Date
Reason for Rescission/Termination Request:

Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a newCOC)
Coverage * r Mistake or Invalid Coverage
f Other
Add ional We information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Ibcurrentation if applicable.
Documentation Mist bePDFformat
Project Close-out Information:
Final Close-out 7/7/2021
Inspection Approval
Project Close-out K75 AV32 SEC-038180-2020 Certificate of
Approval 135.44KB
Completion 070721.pdf
Documentation
Mist be Ft7Fforrrat
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 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 not to exceed ten thousand
dollars ($10,000).
I7 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
["�t2i � diler�c�
Type Name* Gerri R. Herakovich
Title * Member Manager
Organization* Robuck Design Build, LLC
Date * 07/28/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 919-422-2858
NOT Certification AV032 NOT Certification. pdf 471.39KB
Form Mist be PDF Format

Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCdonNiotificationErrails
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]