NCC204502_Notice of Termination_20211117

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/17/2021 9:50:18 PM (NOT Submittal)
Approve by Morman, Alaina 11/18/2021 9:25:53 AM (NOT Request Review - NCC204502)
• The task was assigned to Morman, Alaina. The due date is: November 22, 2021 5:00 PM
11/17/2021 9:50 PM

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NORTH CAROLINA
EnOmnmertray Quduly
Certificate of NCC204502
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
May be blank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request until
payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must be
completed first (at the NOD or NOV Review step) to ensure records are routed to the correct folder in the repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
40 Plantation Drive
Address
40 Plantation Drive, Southern Pines, NC
County
Moore
Latitude
35.1920
Longitude
-79.4240
Permittee Listed
Latitude Builders, LLC
Legally Responsible
Tyler Cook
Individual
NC Reference No.
NCG01-2020-4502
E&SC Plan ID
20-3732
Original NOI Tracking
32550
No.
Date COC Issued
10/8/2020
Prior Rescission Date
Date populates only if COC was already rescinded at time of submittal.
Reason for Rescission/Termination Request:
Reason for Project Closed -Out
Termination of Sale (Another Owner/Operator obtained a new COC)
Coverage* Mistake or Invalid Coverage
Other
Additional More information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation Must be PDF format
Project Close-out Information:
Final Close-out 11/16/2021
Inspection Approval
Project Close-out Inspection Card (2).pdf 78.36KB
Approval Erosion Control Closeout Letter 11.16.21.pdf 75.53KB
Documentation
Must be PDF format
North Carolina General Statute 143-215.6B (1) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document
filed 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 device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
7 rr� C-111
Type Name* Tyler B Cook
Title* owner
Organization* Latitude Builders, LLC
Date * 11 /17/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9106903969
NOT Certification 40 plantation NOT form.pdf 542.34KB
Form Must be PDF Format
Is this CDC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emails
(Optional)
Original Permittee CC'd on Notification Emails
Email [e-mail]

Original Site Contact cc'd on Notificaiton Emails
Email [e-mail]