NCC201543_Notice of Termination_20210916

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/16/2021 11:02:47 AM (NOT Submittal)
Approve by Morman, Alaina 9/19/2021 1:36:50 PM (NOT Request Review- NCC201543)
• The task was assigned to Morman, Alaina. The due date is: September 21, 2021 5:00 PM
9/16/2021 11:02 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201543
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
fvby be blank (if not yet billed).
Information associated with this permit:
Project Name
Chatham Park Section 5 - Vineyard Park (Stage 1)
Address
362 Vine Parkway, Pittsboro, NC
County
Chatham
Latitude
35.7250
Longitude
-79.1587
Permittee Listed
Chatham Park Investors LLC
Legally Responsible
Tim Smith
Individual
NC Reference No.
NCG01-2020-1543
E&SC Plan ID
2020-02301
Original NOI
24456
Tracking No.
Date COC Issued
4/17/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
r Mistake or Invalid Coverage
r Other
Additional We information about the basis of this request, if needed.
Explanation Final Termination - Close-out of Stage 2
Erosion Control

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 8/26/2021
Inspection Approval
Project Close-out CERTIFICATE OF COMPLETION -Vineyard Park
Approval Stage 2-8.26.21.pdf
Documentation
Mast be RYformat
North Carolina General Statute 143-215.613 (i) provides that:
34.46KB
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 Artide; 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
Type Name* Robin R. Rose
Title * Registered Agent
Organization* Chatham Park Investors LLC
Date * 09/16/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9194177889
NOT Certification 20210915_CP Vineyard Park NCG01-eNOT-
Form 64.04KB
Certification -Form -Sig ned. pdf
Mast be FDF Forrrst
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) [e-mail]
Original Permittee 0Cd on Wif ication Bi ails
Email [e-mail]

Original Site Contact GCd on Wificaiton Blails
Email [e-mail]