NCC192987_Notice of Termination_20210114

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/14/2021 12:12:57 PM (NOT Submittal)
Approve by Morman, Alaina 1/15/2021 1:47:09 PM (NOT Request Review- NCC192987)
• The task was assigned to Morman, Alaina. The due date is: January 19, 2021 5:00 PM
1/14/2021 12:13 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC192987
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
Camberly Lot 10
Address
7713 Dover Hills Dr., Wake Forest, NC
County
Wake
Latitude
35.9908
Longitude
-78.5729
Permittee Listed
ICG Homes, LLC
Legally Responsible
Ryan Perry
Individual
NC Reference No.
NCGO1-2019-2987
E&SC Plan ID
SEC-028951-2019
Original NOI
18969
Tracking No.
Date COC Issued
12/3/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 1/12/2021
Inspection Approval
Project Close-out CAM010 - SEC-028951-2019 Certificate of
Approval 1.23MB
Completion.pdf
Documentation
Mast be Ft7Fforrrat
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).
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* Ryan Perry
Title * Owner
Organization* ICG Homes, LLC
Date * 01 /14/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 8033481944
NOT Certification CAM010 - NCG01 NOT Cert. Form.pdf 685.75KB
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
CCd on Notification B ails
[e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]