NCC204578_Notice of Termination_20230108

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/8/2023 9:58:58 PM (NOT Submittal)
Approve by Clark, Paul B 1/12/2023 7:56:40 PM (NOT Request Review - NCC204578)
• The task was assigned to Clark, Paul B by round robin distribution 1/8/2023 9:59 PM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: January 12, 2023 5:00
PM 1/8/2023 9:59 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(COC) will be rescinded.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 NCC204578
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 PAID PAID
May be blank if N/A May be blank if N/A
2023 Annual Fee Status
May be blank if N/A
Information associated with this permit:
Project Name Peterson Station
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
8811 Stephenson Road, Holly Springs, NC
County
Wake
Latitude
35.6800
Longitude
-78.8090
Permittee Listed
Sunset Gateway, LP
Legally Responsible
Jeff Peterson
Individual
NC Reference No.
NCG01-2020-4578
E&SC Plan ID
16-17-01
Original NOI Tracking
32859
No.
Date COC Issued
10/20/2020
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Date populates only if COC was already rescinded at time of submittal.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

New owner/operator NCC230007
COC No. Enter the COC number obtained by the new owner
New Owner Name First and last name
PR III /DRP Holly Springs Station LP
New Owner Phone [phone], Jody Booth
Number
New Owner Email [e-mail]
Additional More information about the basis of this request, if needed.
Explanation See email from Paul Clark 12/02/2022
Supporting Upload Supporting Documentation if applicable.
Documentation Peterson Station Cert of Compliance.pdf 24.91 KB
NCDEQ FRO - Execute Sunset.pdf 130.77KB
Certificate of Coverage.pdf 36.45KB
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 143-215.613 (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
'Te��4el Pe1eY3'9)4
Type Name* Jeff Peterson
Title* Managing Partner
Organization * Sunset Gateway, LP
Date * 01 /08/2023

Email for [e-mail]
Confirmation*
Contact Telephone* 9194682639
NOT Certification NOT Recession.pdf
Form Must be PDF Format
Is this COC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional)
Original Permittee CGd on Notification Emails
Email [e-mail]
Original Site Contact CCd on Notificaiton Emails
Email [e-mail]
784.21 KB