NCC191890_Notice of Termination_20201203

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/3/2020 1:38:04 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/3/2020 1:45:38 PM (NOT Request Review- NCC191890)
• The task was assigned to Georgoulias, Bethany. The due date is: December 8, 2020 5:00 PM
12/3/2020 1:38 PM

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NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191890
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Westfall Lot 113
Address
64 West Beech Slope Ct., Chapel Hill, NC
County
Chatham
Latitude
35.8273
Longitude
-79.0522
Permittee Listed
ICG Homes, LLC
Legally Responsible
Ryan Perry
Individual
NC Reference No.
NCG01-2019-1890
E&SC Plan ID
2019-07413
Original NOI
15878
Tracking No.
Date COC Issued
9/16/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * O Mistake or Invalid Coverage
r Other
Addional We inforrration about the basis of this request, if needed.
Explanation
Supporting upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 11/30/2020
Inspection Approval

Project Close-out WFL113 - CERTIFICATE OF
Approval 293.28KB
COMPLETION _Westfall Lot 113.pdf
Documentation
Mast be Fl7Fforrrat
North Carolina General Statute 143-215.6E (i) provides that:
Any person who knowingly makes anyfalse 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 deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which may include a fine not to exceed ten thousand
dollars ($10,000).
17 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
?,K ` •tom
Type Name* Ryan Perry
Title * Owner
Organization* ICG Homes, LLC
Date * 12/03/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 8033481944
NOT Certification WFL113 - NCG01 NOT Cert Form.pdf
Form Mast be PDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
802.03KB