NCC201295_Notice of Termination_20201112

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/12/2020 6:04:07 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/13/2020 8:16:04 AM (NOT Request Review- NCC201295)
• The task was assigned to Georgoulias, Bethany. The due date is: November 17, 2020 5:00 PM
11/12/2020 6:04 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201295
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Stonewater Lot 167
Address
800 Brownwich St., Wake Forest, NC
County
Wake
Latitude
35.9336
Longitude
-78.4973
Permittee Listed
ICG Homes, LLC
Legally Responsible
Ryan Perry
Individual
NC Reference No.
NCG01-2020-1295
E&SC Plan ID
SEC-031239-2020
Original NOI
23746
Tracking No.
Date COC Issued
4/1/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * O Mistake or Invalid Coverage
r Other
Addional Mxe inforrration 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 11/5/2020
Inspection Approval

Project Close-out STW167 - SEC-031239-2020 Certificate of
Approval 164.11 KB
Completion_Lot 167_11-5-20.pdf
Documentation
Mast be FL7Fforrrat
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 Article or a rule implementing this Article; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowinglyrenders
inaccurate anyrecording or monitoring deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto 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
?,K ` •tom
Type Name* Ryan Perry
Title * Owner
Organization* ICG Homes, LLC
Date * 11 /12/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9198765802
NOT Certification STW167 - NCG01 NOT Cert Form.pdf
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since submttal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
767.74KB