NCC204334_Notice of Termination_20210820

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/20/2021 11:26:03 AM (NOT Submittal)
Approve by Morman, Alaina 8/20/2021 5:00:11 PM (NOT Request Review- NCC204334)
• The task was assigned to Morman, Alaina. The due date is: August 25, 2021 5:00 PM
8/20/2021 11:26 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC204334
Coverage (COC) Enter the Certificate of Coverage Nimber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Eastover North, Section One, Phase Two -Lots 74, 76 & 77
Address
Ives Drive, Eastover Township, NC
County
Cumberland
Latitude
35.1080
Longitude
-78.7780
Permittee Listed
A&G Residential, LLC
Legally Responsible
Jamie Godwin
Individual
NC Reference No.
NCG01-2020-4334
E&SC Plan ID
CUMBE-2021-016
Original NOI
32094
Tracking No.
Date COC Issued
10/6/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 8/20/2021
Inspection Approval
Project Close-out AG EASTOVER NORTH CUMBE-2021-016
Approval 163.43KB
INSP20210810 CO.pdf
Documentation
Mist 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
Type Name* Jamie C. Godwin
Title * Member -Manager
Organization* A&G Residential LLC
Date * 08/20/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9107790229
NOT Certification NOT EON 74, 76 & 77 20210820.pdf
Form Mast be PDF Fornat
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 STails
Email [e-mail]
669.76KB