NCC204777_Notice of Termination_20211001

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/1/2021 10:00:33 AM (NOT Submittal)
Approve by Morman, Alaina 10/5/2021 7:54:35 AM (NOT Request Review- NCC204777)
• The task was assigned to Morman, Alaina. The due date is: October 6, 2021 5:00 PM
10/1/2021 10:00 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC204777
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
Nby be blank (if not yet billed).
Information associated
with this permit:
Project Name
Camberly 8
Address
7705 DOVER HILLS Drive, Wake Forest, NC
County
Wake
Latitude
35.9833
Longitude
-78.5712
Permittee Listed
Exeter Building Company
Legally Responsible
Alexander Yost
Individual
NC Reference No.
NCG01-2020-4777
E&SC Plan ID
SEC-045455-2020
Original NOI
33645
Tracking No.
Date COC Issued
10/26/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 MstbeRYforrrat

Project Close-out Information:
Final Close-out 8/16/2021
Inspection Approval
Project Close-out SEC-045455-2020 Certificate of Completion (1).pdf 137.32KB
Approval Mast be FDFfornat
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 under this 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 Artcle 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
K-Ar !vc1C
Type Name* Alex Yost
Title * Managing Member
Organization* Exeter Building Company LLC
Date * 10/01 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9193580873
NOT Certification Camberly 8 NOT.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)
Original Permittee CCd on Notification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
414.18KB