NCC204633_Notice of Termination_20211008

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/8/2021 2:28:35 PM (NOT Submittal)
Approve by Morman, Alaina 10/11/2021 6:23:34 PM (NOT Request Review- NCC204633)
• The task was assigned to Morman, Alaina. The due date is: October 13, 2021 5:00 PM
10/8/2021 2:28 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC204633
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
May be blank (if not yet billed).
Information associated with this permit:
Project Name
Pennington Lot 20
Address
63 E. Antebellum Dr, Pittsboro, NC
County
Chatham
Latitude
35.7370
Longitude
-79.0660
Permittee Listed
Triple A Homes
Legally Responsible
Gerry Felton
Individual
NC Reference No.
NCG01-2020-4633
E&SC Plan ID
2020-06731
Original NOI
33039
Tracking No.
Date COC Issued
10/14/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 Nbre inforrration about the basis of this request, if needed.
Explanation Construction complete.
Supporting upload Supporting Qbcurrentation if applicable.
Documentation Mast beRYforrrat

Project Close-out Information:
Final Close-out 10/6/2021
Inspection Approval
Project Close-out PEN 20 Certificate of Completion.pdf 287.89KB
Approval Must 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 Amide; 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
Type Name* Gerry Felton
Title * VP
Organization * Triple A Homes
Date * 10/08/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9498120991
NOT Certification PEN 20 NCG01-eNOTermination-Certification-Form-
Form 1.03MB
20190508-DEML R-SW. pdf
Mist be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Er ails
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]