NCC200139_Notice of Termination_20220311

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/11/2022 11:44:30 AM (NOT Submittal)
Approve by Morman, Alaina 3/18/2022 10:38:10 AM (NOT Request Review - NCC200139)
• The task was assigned to Morman, Alaina. The due date is: March 16, 2022 5:00 PM
3/11/2022 11:44 AM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC200139
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status
2021 Annual Fee Status PAID
May be blank (if not yet billed).
2022 Annual Fee PAST DUE
Status 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
Fairfield Inn & Suites Wallace
Address
Hwy 41 & River Place, Wallace, NC
County
Duplin
Latitude
34.7555
Longitude
-77.9486
Permittee Listed
Duplin Land Development, Inc.
Legally Responsible
Terry Tate
Individual
NC Reference No.
NCG01-2020-0139
E&SC Plan ID
DUPLI-2020-014
Original NOI Tracking
20479
No.
Date COC Issued
1/14/2020
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Date populates only if COC was already rescinded at time of submittal.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 new COC)
Coverage* Mistake or Invalid Coverage
• Other Terminated Project

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
Inspection Approval
Project Close-out Must be PDF format
Approval
Documentation
North Carolina General Statute 143-215.613 (i) 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
lzlly 6) col - t1:
Type Name* Danny K Best Jr.
Title* Heavy Equipment/Fleet Maintenance Manager
Organization* Murphy Family Ventures: Duplin Land Development
Date * 03/11 /2022
Email for [e-mail]
Confirmation *
Contact Telephone* 910-271-0362
NOT Certification Xerox _Scan.pdf 78.29KB
Form Xerox_Scan_001.pdf 46.04KB
Must be PDF Format
Is this COC 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 Notificaiion Emails
Email [e-mail]