NCC191402_Notice of Termination_20201218

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/18/2020 8:43:44 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/18/2020 1:44:14 PM (NOT Request Review- NCC191402)
p Applicant inadvertently uploaded NOI certification form instead. Provided NOT Certification form via e-
mail (will be added to permit record).
• The task was assigned to Georgoulias, Bethany. The due date is: December 23, 2020 5:00 PM
12/18/2020 8:43 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC191402
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status
N/A
Information associated
with this permit:
Project Name
1312 N Patterson Ave
Address
N Patterson Ave, Winston-Salem, NC
County
Forsyth
Latitude
36.1113
Longitude
-80.2421
Permittee Listed
Jerry Deakle & Associates, Inc.
Legally Responsible
Jerry Deakle
Individual
NC Reference No.
NCG01-2019-1402
E&SC Plan ID
2019-048
Original NOI
14908
Tracking No.
Date COC Issued
9/17/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
O Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 10/15/2019
Inspection Approval
Project Close-out CLOSE OUT —Sedimentation Inspection
Approval 39.16KB
Report _Oct _11 _2019. pdf
Documentation
Mast be Ft7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled 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 underthis 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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
rJ 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
Type Name* Jerry P. Deakle
Title * President
Organization * Jerry Deakle & Assoc., Inc.
Date * 12/18/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-782-1703
NOT Certification NCG01_1312 Patterson Ave_Winston-Salem.pdf
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
73.5KB