NCC203470_Notice of Termination_20210811

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 8/11/2021 1:25:51 PM(NOT Submittal)
Approve by Morman,Alaina 8/11/2021 4:02:33 PM(NOT Request Review-NCC203470)
• The task was assigned to Morman,Alaina.The due date is:August 16,2021 5:00 PM
8/11/2021 1:25 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 NCC203470
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 Stonewater S/D Phase 5 Lot 185
Address 1209 Argentum St, Rolesville, NC
County Wake
Latitude 35.9290
Longitude -78.4979
Permittee Listed Exeter Building Company
Legally Responsible Alex Yost
Individual
NC Reference No. NCG01-2020-3470
E&SC Plan ID SEC-041089-2020
Original NOI 29680
Tracking No.
Date COC Issued 8/13/2020
Prior Rescission Cate populates only if COC was already rescinded at tirre of subrrittal.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
Addional IVbre inforrration 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 6/18/2021
Inspection Approval
Project Close-out SEC-041089-2020_Certificate of Completion_6-18-
Approval 134.46KB
21 (2).pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66(1) provides that:
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
K-Ar lvc1C
Type Name* Alex Yost
Title* Managing Member
Organization* Exeter Building Company
Date* 08/11/2021
Email for [e-mail]
Confirmation
Contact Telephone* 9194551664
NOT Certification Stonewater 185 NOT.pdf 420.98KB
Form Mast be PDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]

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