NCC192977_Notice of Termination_20210215

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/15/2021 10:53:28 PM (NOT Submittal)
Approve by Morman, Alaina 2/28/2021 9:10:52 PM (NOT Request Review- NCC192977)
p New Hanover County inspected the site and verified that the additional land disturbing activity permitted
by their office never occurred, and they have closed the land disturbance permit.
• The task was assigned to Morman, Alaina. The due date is: February 18, 2021 5:00 PM
2/15/2021 10:53 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192977
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
Avalon South
Address
1833 Avalon Ave, Wilmington, NC
County
New Hanover
Latitude
34.0000
Longitude
-78.0000
Permittee Listed
N/A
Legally Responsible
Michael Jackson
Individual
NC Reference No.
NCG01-2019-2977
E&SC Plan ID
GP 78-06
Original NOI
18964
Tracking No.
Date COC Issued
12/3/2019
Prior Rescission
Cate populates only if CDC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
F Sale (Another Owner/Operator will apply for a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other

Add ional We information about the basis of this request, if needed.
Explanation Property sold 12-18-2019
Supporting Upload Supporting Documentation if applicable.
Documentation Deed Sale of 1833 Avalon Ave - Avalon South.pdf 114.49KB
Mast be FDFforrrat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFformat
Approval
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this A tide or a rule implementing this A tide; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording or monitoring device 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 notto 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* Michael Jackson
Title * Former Owner
Organization* None
Date * 02/15/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 910-508-2518
NOT Certification NCG01 Notice of Termination Form.pdf 566.32KB
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Wification En -ails
(Optional)

Original Permittee CCdonKlotificationEn-ails
Email [e-mail]
Original Site Contact GCd on Wificaiton Erails
Email [e-mail]