NCC201746_Notice of Termination_20210901

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/1/2021 10:32:46 AM (NOT Submittal)
Approve by Morman, Alaina 9/3/2021 4:18:56 PM (NOT Request Review- NCC201746)
• The task was assigned to Morman, Alaina. The due date is: September 6, 2021 5:00 PM
9/1/2021 10:32 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201746
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
Nby 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
Caropines Phase 2A Lot 13
Address
675 Avenue of the Carolinas, Southern Pines, NC
County
Moore
Latitude
35.0000
Longitude
-79.0000
Permittee Listed
Caropine Ventures, LLC
Legally Responsible
Perry Shelley
Individual
NC Reference No.
NCG01-2020-1746
E&SC Plan ID
20-1005
Original NOI
24823
Tracking No.
Date COC Issued
5/13/2020
Prior Rescission
Cate populates only if OOCwas already rescinded at tirre of subaittal.
Date
Reason for Rescission/Termination Request:

Reason for f Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a newCOC)
Coverage * r Mistake or Invalid Coverage
r Other 1
Add ional We information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Cbcurrentation if applicable.
Documentation 20210727160429630 deq 1ot13.pdf
20210901102730283.pdf
Ntast be PDFforrrat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist bePDFforrat
Approval
Documentation
North Carolina General Statute 143-215.6113 (i) provides that:
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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 device or method required to be operated or maintained under this Article 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
Type Name* perry shelley
Title * vp
Organization* caropine ventures , LLC
Date * 09/01 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 19108643232

NOT Certification 20210901102730283.pdf
Form Mist be FDF Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email OCd on Notification Errails
(Optional)
Original Permittee 0Cd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Emils
Email [e-mail]
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