NCC191591_Notice of Termination_20210817

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/17/2021 1:18:42 PM (NOT Submittal)
Approve by Morman, Alaina 8/18/2021 11:12:17 AM (NOT Request Review- NCC191591)
• The task was assigned to Morman, Alaina. The due date is: August 20, 2021 5:00 PM
8/17/2021 1:18 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191591
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
fvhy be blank (if not yet billed).
Information associated with this permit:
Project Name
Ashberry Phase 1C - Long Mill Road Widening
Address
Ashberry Lane, Franklinton, NC
County
Franklin
Latitude
36.0000
Longitude
-79.0000
Permittee Listed
Dan Ryan Builders - North Carolina, LLC
Legally Responsible
Jay Lewis
Individual
NC Reference No.
NCG01-2019-1591
E&SC Plan ID
FRANK-2019-028
Original NOI
15258
Tracking No.
Date COC Issued
8/28/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.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 Nbre information about the basis of this request, if needed.
Explanation Work is completed and inspected. Close out
inspection report is attached.

Supporting Upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 8/17/2021
Inspection Approval
Project Close-out Closeout Inspection Report - Ashberry 1 C - Long
Approval Mill Rd.pdf
Documentation
Mast be RYformat
North Carolina General Statute 143-215.613 (i) provides that:
173.6KB
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 of the
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
�� We&
Type Name* Taylor Holt
Title * Land Development Manager
Organization* Dan Ryan Builders North Carolina, LLC
Date * 08/17/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9194071149
NOT Certification NOT - Certification Form - Ashberry 1 C.pdf 26.9KB
Form Mast be FDF Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email OCd on Notification Errails
(Optional)
Original Permittee CCd on Wification Errails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]