NCC202933_Notice of Termination_20210926

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/26/2021 9:03:28 PM (NOT Submittal)
Approve by Morman, Alaina 9/27/2021 4:47:17 PM (NOT Request Review- NCC202933)
• The task was assigned to Morman, Alaina. The due date is: September 30, 2021 5:00 PM
9/26/2021 9:03 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC202933
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
Nby be blank (if not yet billed).
Information associated with this permit:
Project Name
Davencroft House lot 30
Address
4327 Dublin rd, Greenville, NC
County
Pitt
Latitude
35.5530
Longitude
-77.4240
Permittee Listed
Jorge Ramos
Legally Responsible
Jorge Ramos
Individual
NC Reference No.
NCG01-2020-2933
E&SC Plan ID
ESCP-2020-0041
Original NOI
28073
Tracking No.
Date COC Issued
7/13/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
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 IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation Mist beRYforrrat

Project Close-out Information:
Final Close-out 9/21/2021
Inspection Approval
Project Close-out LETTER OF FINAL INSPECTION 3.pdf 480.58KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (i) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho 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 notto 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* JORGE RAMOS
Title * OWNER
Organization* JORGE RAMOS
Date * 09/26/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 2527173644
NOT Certification NOT FORM 3 (1).pdf
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
580.05KB