NCC203008_NOT Signed Certification_20220804

DEQIA Notice of Termination (NOT) Request -
N°R�cofEnvi — NPDES Stormwater Permit for Construction
Department of Environmental llualiry
Activities
Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCG010000 (or NCG250000). If approved, the Certificate of
Coverage (COC) will be rescinded.
Certificate of NCC203008
Coverage (COC) Enter the Certificate of Coverage Number (Use capital letters)
No. *
Information associated with this permit:
Project Name Royal Oak of Pinehurst - Phase 2
Address Murdocksville Road, Pinehurst, NC
County Moore
Latitude 35.0000
Longitude-79.0000
Permittee Listed Tiara Properties, LLC
Legally Responsible Richard Knight
Individual
E&SC Plan ID MOORE-2020-049
Original NOI 28183
Tracking No.*
Date COC Issued * 07/21 /2020
Prior Rescission This field will populate only if COC has already been rescinded.
Date
Reason for Rescission/Termination Request:

Reason for Q Project Closed -Out
Termination of Q Sale (Another Owner/Operator obtained new COC)
Coverage* Q Mistake or Invalid Coverage
Q Other
Additional More information about the basis of this request, if needed.
Explanation
For Project Close-out, you must provide documentation below. Please note, a Certificate of
Occupancy is not sufficient close-out documentation. You must provide a final inspection report or
correspondence from the authority that approved the Erosion and Sediment Control (E&SC) Plan.
Erosion Control Plan 1/3/2022
Close-out Date*
Erosion Control Plan PLAT PHASE II SIGNED AND RECORDED 01-0... 569.06KB
Close-out Must be PDF format
Documentation*
North Carolina General Statute 143-215.6B (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.
Important: The person who electronically signs this Certification must be the same person who signs the paper NOT
Certification Form (uploaded below). If that person is signing on behalf of the Permittee, that individual must be an
authorized responsible person within the same organization as the Permittee.
*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* Richard Knight
Title* Member -Manager
Organization* Tiara Properties, LLC
Date * 07/19/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 910.682.4970
YOU MUST MAIL THE ORIGINAL SIGNED NOT CERTIFICATION FORM (click on this link) to The Stormwater
Program at the address on the form for the application to fulfill federal requirements. You must also upload a copy of
that completed below:
NOT Certification NPDES NCG01 Notice of Termination Certificatio... 296.78KB
Form * Must be PDF Format
Additional Email
(Optional)