NCC216841_Notice of Termination_20230330

4/14/23, 10:56 AM
NOT Request Review - NCC216841
D E Q , Notice of Termination (NOT) Re^ques1t -e -r ��- l
NORTH°AROLMA -\ NPDES Stormwater Permit f^r ■ _^hCTri itT�^h
NORTHeC REnvironmental Quality
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 NCGO10000 (or NCG250000). If approved, the Certificate of
Coverage (COC) will be rescinded.
Certificate of NCC216841
Coverage (COC) Enter the Certificate of Coverage Number
No.*
2020 Annual Fee Status 2021 Annual Fee Status
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 Rufus Johnson Road Subdivision - Lots 17-21
2022 Annual Fee Status
PAI D
May be blank if N/A
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 Rufus Johnson Road (SR-2258), Grays Creek Township, NC
County Cumberland
Latitude 34.8385
Longitude-78.8936
Permittee Listed A&G Residential, LLC
Legally Responsible Jamie Godwin
Individual
NC Reference No. NCG01-2021-6841
https://edocs.deq.nc.gov/Forms/form/submission/history/l35027/356107?hideHeader=true&showlnstanceDetails=false&frominstances=true 1/3

4/14/23, 10:56 AM
NOT Request Review - NCC216841
E&SC Plan ID
Original NOI
Tracking No.
Date COC Issued
Prior Rescission
Date
CUMBE-2022-067
75296
12/13/2021
Date populates only if COC was already rescinded at time of submittal.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
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:
Erosion Control Plan 3/22/2023
Close-out Date
Erosion Control Plan Cumbe-2022-067.pdf
Close-out Must be PDF format
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
37.92KB
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.
https://edocs.deq.nc.gov/Forms/form/submission/history/l35027/356107?hideHeader=true&showlnstanceDetails=false&frominstances=true 2/3

4/14/23, 10:56 AM
NOT Request Review - NCC216841
*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
Type Name* Jamie Godwin
Title* Member Manager
Organization * A&G Residential LLC
Date * 03/30/2023
Email for [e-mail]
Confirmation *
Contact Telephone* 9107790229
NOT Certification NOT.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]
416.46KB
https://edocs.deq.nc.gov/Forms/form/submission/history/l35027/356107?hideHeader=true&showinstanceDetails=false&frominstances=true 3/3

NOT Request Review- NCC216841
DEMLR- NCGOt recal lon NCQt6&At: RUNS Johnson Road Subdanslon-fork 17-21
Use this form to submit a Nadu of Termination (NOT) request for a project covered under the N.C. NPOES
General Permitfor Construction Activities NCGOIDOOO (or NCG250000). If approved, the Crimicale of Coverage
(COC) all be rescinded.
Cetllficate of NCC216MI
Coverage(COC) fill rmeFfkaigeaaaremenvers9eNrover
2020 Annual Fee Stamps 2021 Annual Fee Status 2022 Annual Fee Status
May te blank if wA May Pa blank ff wA PAID
May he all ff KA
2023 Annual Fee Status
May Job blank ff NVA
Ell
NOT Request Revel NCC216841
OEMIR-NCCA1 Ilea lan NCO16MI Rrfaishown
Summary Action History
/ i� Process Completed
41cl 9:58 AM
416AA238:53 AM
V PaulkElarkmmpletedtask Niell beat n
Review - NCC21613411
J Approve
• The task was assigned to Paul Clark by round
robin distribution on March 30, 2023 12 20 PM
• The task was assigned to OEMCR NCGOI NOT
RessewTeam on March 30, 20231220 PM.
The due date is: April 4, 2023 5:00 PM