NCC203718_Notice of Termination_20210902

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/2/2021 10:43:44 AM (NOT Submittal)
Approve by Morman, Alaina 9/8/2021 12:06:23 PM (NOT Request Review- NCC203718)
New owner's COC number: NCC214432.
• The task was assigned to Morman, Alaina. The due date is: September 7, 2021 5:00 PM
9/2/2021 10:43 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC203718
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
K/hy be blank (if not yet billed).
Information associated
with this permit:
Project Name
Holding Village South Lake Subdivision - Phase 4
Address
0 Friendship Chapel Road (PIN 1840643841), Wake Forest, NC
County
Wake
Latitude
35.9596
Longitude
-78.5059
Permittee Listed
HR North Lake, LLC
Legally Responsible
Dean Barberree
Individual
NC Reference No.
NCG01-2020-3718
E&SC Plan ID
2020-00000127
Original NOI
30411
Tracking No.
Date COC Issued
8/27/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
f Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other Sale (Another Owner/Operator obtained new COC)
Additional IVbre information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation Holding Village Ph. 4 LOR.pdf 42.12KB
Recorded NWD.pdf 128.44KB
Recorded SWD.pdf 168.09KB
STATE - Stormwater NOT - Phase 4 - 9-2-21.pdf 67.72KB
NUst be FDFformat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFformat
Approval
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 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 of the
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* Dean Barberree
Title * Registered Agent
Organization* HR Northlake, LLC
Date * 09/02/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 4078564899
NOT Certification STATE - Stormwater NOT - Phase 4 - 9-2-21.pdf 67.72KB
Form Mast be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]

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