NCC223750_Notice of Termination_20221116

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/16/2022 2:37:35 PM (NOT Submittal)
Approve by Clark, Paul B 11/17/2022 10:51:16 AM (NOT Request Review - NCC223750)
• The task was assigned to Clark, Paul B by round robin distribution 11/16/2022 2:37 PM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: November 21, 2022 5:00
PM 11/16/2022 2:37 PM

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 NCGO10000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC223750
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
May be blank if N/A May be blank if N/A May be blank if N/A
Information associated with this permit
Project Name Eastern Pines Dental
Lots Covered by this This information is especially helpful when more lots were added with Modifications since the original permit
Permit COC (if
issuance.
applicable)
No longer visible on the initial form (data not captured from initial application)
Address
Waterscape Way, New Bern, NC
County
Pitt
Latitude
35.0311
Longitude
-77.0105
Permittee Listed
EPD Properties, LLC
Legally Responsible
Pamela Ward
Individual
NC Reference No.
NCG01-2022-3750
E&SC Plan ID
CRAVE-2023-009
Original NOI Tracking
111733
No.
Date COC Issued
11/4/2022
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Date populates only if COC was already rescinded at time of submittal.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

More information about the basis of this request, if needed.
Additional
Explanation
Supporting
Documentation
We submitted an NOI for the Eastern Pines Dental project on Nov. 1 st and received
a COC (NCC223750). It was then we realized it said Pitt County instead of Craven
County on the COC. I corresponded with Brooklyn Broussard about the possibility of
correcting just the county name and she said we had to submit for a new NOI (which
we did and got approval on November 9th - NCC223789 — see supporting
documentation). She also said we need to submit a NOT for the original COC -
NCC223750. I did this and the NoT was not approved, so I am submitting it again as
per Paul Clark's instructions.
Brooklyn said the New CoC won't be issued until $100 fee from NCC223750 is
transferred to NCC223789, which can't happen until the CoC - NCC223750 is
terminated
Upload Supporting Documentation if applicable.
COC NCC223789 Approval Email.pdf
Must be PDF format
Project Close-out Information:
Erosion Control Plan
Close-out Date
Erosion Control Plan Must be PDF format
Close-out
Documentation
North Carolina General Statute 143-215.6B (i) provides that:
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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
&-A- A7erP
Type Name* Pamela Beavers Ward
Title* Managing Member
Organization * EPD Properties, LLC
Date * 11 /16/2022
Email for [e-mail]
Confirmation*

Contact Telephone* 252-944-3918
NOT Certification Notice of Termination - Executed.pdf
Form 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) [e-mail]
Original Permittee CC'd on Notification Emails
Email [e-mail]
Original Site Contact CC'd on Notificaiton Emails
Email [e-mail]
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