NCC192593_Notice of Termination_20231218

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 12/18/2023 9:05:58 AM (NOT Submittal)
Approve by Kieu Tran 12/19/2023 11:06:44 AM (NOT Request Review-NCC192593)
• The task was assigned to DEMLR NCG01 NOT Review Team.The due date is: December 21,2023 5:00
PM 12/18/2023 9:05:59 AM
• The task was assigned to Kieu Tran by round robin distribution 12/18/2023 9:05:59 AM

Q� Notice of Termination (NOT) Request - NPDE,�tz_
Stormwater Permit for . •
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(COC)will be rescinded.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 NCC192593
Coverage(COC)No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
PAID PAID PAID
May be blank if N/A May be blank if N/A May be blank if N/A
2023 Annual Fee Status
WAIVED
May be blank if N/A
Information associated with this permit:
Project Name Dormie Club-Clubhouse
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 Beulah Hill Church Rd.,West End, NC
County Moore
Latitude 35.2601
Longitude -79.5061
Permittee Listed Sampson Construction Co., Inc.
Legally Responsible Ben Huck
Individual
NC Reference No. NCGO1-2019-2593
E&SC Plan ID MOORE-2020-011
Original NOI Tracking 17919
No.
Date COC Issued 11/12/2019
Prior Rescission Date Date populates only if COC was already rescinded at time of submittal.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

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 10/18/2022
Close-out Date
Erosion Control Plan DEQ SWPPP Final Inspection.pdf 36.38KB
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.
"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
OZ(!hir C'�yyllll
Type Name* Justin J. Hall
Title* Senior Project Manager
Organization* Sampson Construction Co., Inc.
Date* 12/18/2023
Email for [e-mail]
Confirmation*
Contact Telephone* 402-416-6569
NOT Certification DEQ SWPPP NOT Form-Corrected Legally
Form 689.74K6
Responsible Person.pdf
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 Notificaiton Emails
Email [e-mail]