NCC190500_Notice of Termination_20210806

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 8/6/2021 5:23:30 PM(NOT Submittal)
Approve by Morman,Alaina 8/11/2021 2:27:35 PM(NOT Request Review-NCC190500)
• The task was assigned to Morman,Alaina.The due date is:August 11,2021 5:00 PM
8/6/2021 5:23 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 NCC190500
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status PAST DUE
fvby 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 Stevens Grove-Lot 46
Address 1025 Arborfield Drive, Matthews, NC
County Mecklenburg
Latitude 35.1053
Longitude -80.7594
Permittee Listed Kevin Walsh
Legally Responsible Kevin Walsh
Individual
NC Reference No. NCG01-2019-0500
E&SC Plan ID 395915
Original NOI 11774
Tracking No.
Date COC Issued 6/5/2019
Prior Rescission Cate populates only if COC was already rescinded at tine of subrrittal.
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 beFCFforrrat
Project Close-out Information:
Final Close-out 8/6/2021
Inspection Approval
Project Close-out Final.pdf 96.73KB
Approval Mist 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 Artide 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 Artide 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).
17 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
V-1-
Type Name* Kevin Walsh
Title* Home owner
Organization* Home Owner
Date* 08/06/2021
Email for [e-mail]
Confirmation
Contact Telephone* 2406601678
NOT Certification Document_2021-07-31_091039.pdf 269.54KB
Form Mist be FDF Forrrat

Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?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