NCC201281_Notice of Termination_20200401

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/1/2020 2:59:45 PM (NOT Submittal)
Approve by Georgoulias, Bethany 4/1/2020 4:14:27 PM (NOT Request Review- NCC201281)
p Applicant notified DEMLR that address for this site had changed, and we recommended they apply for
another COC. COC No. NCC201323 with the correct address has been issued. Original payment for this
COC was applied.
• The task was assigned to Georgoulias, Bethany. The due date is: April 6, 2020 5:00 PM
4/1/2020 2:59 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201281
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Stonewater Lot 168
Address
712 Brownwich Street, Wake Forest, NC
County
Wake
Latitude
35.9336
Longitude
-78.4973
Permittee Listed
ICG Homes, LLC
Legally Responsible
Ryan Perry
Individual
NC Reference No.
NCG01-2020-1281
E&SC Plan ID
SEC-032392-2020
Original NOI
23772
Tracking No.
Date COC Issued
3/31/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 * r Mistake or Invalid Coverage
F Other Address Changed
Addional We information 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
Inspection Approval

Project Close-out Mast beFDFformat
Approval
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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude 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
oz,r•t�-/
Type Name* Ryan Perry
Title * Owner
Organization* ICG Homes, LLC
Date * 04/01 /2020
Email for [e-mail]
Confirmation *
Contact Telephone* 803-348-1944
NOT Certification STW168 - NCG01 NOT - Addy Change - Cert.
Form Form.pdf
Mast be PM Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]
1.01 MB