NCC192457_Notice of Termination_20210104

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/4/2021 10:40:16 AM (NOT Submittal)
Approve by Georgoulias, Bethany 1/4/2021 10:45:10 AM (NOT Request Review- NCC192457)
• The task was assigned to Georgoulias, Bethany. The due date is: January 7, 2021 5:00 PM
1/4/2021 10:40 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192457
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Grindstone Place
Address
Old Mill Farm Road, Lexington, NC
County
Davidson
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Grindstone Place, LLC
Legally Responsible
Justin Nifong
Individual
NC Reference No.
NCG01-2019-2457
E&SC Plan ID
David-2020-017
Original NOI
17437
Tracking No.
Date COC Issued
10/23/2019
Prior Rescission
Date populates only if OOC was already rescinded at time of submittal.
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 *
r Mistake or Invalid Coverage
r Other Sold property before beginning construction. New owner desires
other use.
Addional IVbre information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation _tmp_416871436.pdf
Mast be FDFfornat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mast beFDFforrrat
Approval
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
222.32KB
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Artide or a rule implementing this Artide; 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 device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
fJ 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* Justin R. Nifong
Title * Manager
Organization* Grindstone Place, LLC
Date * 01 /04/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7045625012
NOT Certification Grindstone NOT.pdf 745.07KB
Form NC NOT termination Grindstone.pdf 399.2KB
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Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)

Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact CCd on Notificaiton B-mils
Email [e-mail]