NCC191354_Notice of Termination_20210111

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/11/2021 8:42:32 AM (NOT Submittal)
Approve by Morman, Alaina 1/12/2021 2:14:04 PM (NOT Request Review- NCC191354)
• The task was assigned to Morman, Alaina. The due date is: January 14, 2021 5:00 PM
1/11/2021 8:42 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191354
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status PAST DUE
2021 Annual Fee Status Nbybeblank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Reviewstep) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Prospect Speedwell
Address
Speedwell Road (SR 1001), Cullowhee, NC
County
Jackson
Latitude
35.2952
Longitude
-83.1790
Permittee Listed
The Cloverleaf Group
Legally Responsible
Drew Wren
Individual
NC Reference No.
NCG01-2019-1354
E&SC Plan ID
19-108
Original NOI
14772
Tracking No.
Date COC Issued
8/15/2019
Prior Rescission
Cate populates only if CDC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
C Project Closed -Out
Termination of
Q Sale (Another Owner/Operator will apply for a new COC)
Coverage *
a Mistake or Invalid Coverage
0 Other

Add ional Mare infornation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mast beFCFforrat
Project Close-out Information:
Final Close-out 1/5/2021
Inspection Approval
Project Close-out COC-NOT.pdf 119.23KB
Approval Mast be FDFfornat
Documentation
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 of the
Commission implementing this Artcle 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* Ashley Hill
Title * Managing Member
Organization * The Cloverleaf Group/Prospect Speedwell LLC
Date * 01 /11 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7062152104
NOT Certification COC-NOT.pdf 119.23KB
Form Mast be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification En -ails
(Optional)

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