NCC205014_Notice of Termination_20210203

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/3/2021 8:23:44 AM (NOT Submittal)
Approve by Morman, Alaina 2/4/2021 4:55:22 PM (NOT Request Review- NCC205014)
• The task was assigned to Morman, Alaina. The due date is: February 8, 2021 5:00 PM
2/3/2021 8:23 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC205014
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Twin Coves Lots 27 & 28 EC Permit Only
Address
13800 ISLAND DR HUNTERSVILLE, Huntersville, NC
County
Mecklenburg
Latitude
35.4325
Longitude
-80.9363
Permittee Listed
Ibex Company LLC
Legally Responsible
Andrew Falls
Individual
NC Reference No.
NCG01-2020-5014
E&SC Plan ID
410651
Original NOI
35001
Tracking No.
Date COC Issued
11/5/2020
Prior Rescission
Date populates only if OOC was already rescinded at tirre of submittal.
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
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 2/2/2021
Inspection Approval
Project Close-out Twin Coves Final Inspection.pdf 281.17KB
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 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 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
A>t Aew FJ11s
Type Name* Andrew Falls
Title * Registered Agent
Organization * Ibex Company, LLC
Date * 02/03/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7045740419
NOT Certification Signed NOT Cert Form.pdf 201.16KB
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Erails
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]