NCC203603_Notice of Termination_20210805

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 8/5/2021 5:01:35 PM(NOT Submittal)
Approve by Morman,Alaina 8/10/2021 10:27:23 AM(NOT Request Review-NCC203603)
• The task was assigned to Morman,Alaina.The due date is:August 10,2021 5:00 PM
8/5/2021 5:01 PM

" RequestNOT • Construction Stormwater
1 i
�a•aThis formto request Notice of • • for •co\erage under •
NORTH CAROLINA General - for • i i• Activities Qr�arrry
Certificate of NCC203603
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 Southern Crossroads Ralph Stephens Rd. Sidewalk
Address 2051 Ralph Stephens Road, Holly Springs, NC
County Wake
Latitude 35.6333
Longitude -78.8343
Permittee Listed Southern Crossroads, Inc.
Legally Responsible Brantley Powell
Individual
NC Reference No. NCG01-2020-3603
E&SC Plan ID 19-2020
Original NOI 30042
Tracking No.
Date COC Issued 8/20/2020
Prior Rescission Cate populates only if COC was already rescinded at time of submittal.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 Mist beRYforrrat

Project Close-out Information:
Final Close-out 4/22/2021
Inspection Approval
Project Close-out 4-22-21 Southern Crossroads Ralph Stephens
Approval 141.88KB
Sidewalk(Certificate of Completion S&EC).pdf
Documentation
Mast be FDFforrrat
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
C�rWwl
Type Name* H. Brantley Powell
Title* President
Organization* Southern Crossroads, Inc.
Date* 08/05/2021
Email for [e-mail]
Confirmation
Contact Telephone* 919-656-7500
NOT Certification NCDEMLRNOTForm8.2.21.pdf 558.92KB
Form Mast be PDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]

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