NCC205795_Notice of Termination_20210806

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 8/6/2021 2:28:02 PM(NOT Submittal)
Approve by Morman,Alaina 8/11/2021 2:16:53 PM(NOT Request Review-NCC205795)
• The task was assigned to Morman,Alaina.The due date is:August 11,2021 5:00 PM
8/6/2021 2:28 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 NCC205795
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank(if not yet billed).
Information associated with this permit:
Project Name Winds Way Farm-Lots 97, 98, 99, 101, 102&111
Address Winds Way/Thistleberry Dr,Sandhills, NC
County Moore
Latitude 35.0000
Longitude -79.0000
Permittee Listed Caviness Land Development, Inc
Legally Responsible Watson Caviness
Individual
NC Reference No. NCG01-2020-5795
E&SC Plan ID MOORE-2021-046
Original NOI 39065
Tracking No.
Date COC Issued 12/15/2020
Prior Rescission Date populates only if OOC was already rescinded at tine of subaittal.
Date
Reason for Rescission/Termination Request:
Reason for r Project Closed-Out
Termination of r Sale(Another Owner/Operator obtained a new COC)
Coverage* U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre inforrration about the basis of this request,if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat

Project Close-out Information:
Final Close-out 7/16/2021
Inspection Approval
Project Close-out Close out inspection 7.16.21.pdf 37.31KB
Approval Mast be FDFforrrat
Documentation
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
+j��rl�at�r.��`�rrr�sr�lrl
Type Name* Watson G Caviness
Title* President
Organization* Caviness Land Development
Date* 08/06/2021
Email for [e-mail]
Confirmation
Contact Telephone* 910-339-6330
NOT Certification NOT cert form.pdf 303.81 KB
Form Mast be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact OCd on Notificaiton Errails
Email [e-mail]

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