NCC192007_Notice of Termination_20210302

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/2/2021 12:31:36 PM (NOT Submittal)
Approve by Morman, Alaina 3/4/2021 11:04:52 AM (NOT Request Review- NCC192007)
• The task was assigned to Morman, Alaina. The due date is: March 5, 2021 5:00 PM
3/2/2021 12:31 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192007
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
Perry Farms Lots 15, 17, 71
Address
1429 Sweetclover Dr, Wake Forest, NC
County
Wake
Latitude
36.0000
Longitude
-78.0000
Permittee Listed
Gemstone Homes LLC
Legally Responsible
Chris Schiavone
Individual
NC Reference No.
NCG01-2019-2007
E&SC Plan ID
SEC-023216-2019
Original NOI
16117
Tracking No.
Date COC Issued
9/24/2019
Prior Rescission
Cate populates only if CDC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
C Project Closed -Out
Termination of
Q Sale (Another Owner/Operator obtained a new COC)
Coverage *
a Mistake or Invalid Coverage
0 Other

Add ional Nbre infornation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation Mist bePDFforrat
Project Close-out Information:
Final Close-out 3/1/2021
Inspection Approval
Project Close-out SEC-023216-2019-Certificate of Completion_Perry
Approval 138.33KB
Farm Lot 15, 17, 71.pdf
Documentation
Mast be FDFforrrat
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 Artide or a rule implementing this Article; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Arficle; orwho falsifies, tampers with, or knowingly renders
inaccurate any recording or monitoring deice or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Arficle 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
G`'l? -'; 7, e-0-rw
Type Name* Chris Schiavone
Title * President
Organization* Gemstone Homes
Date * 03/02/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 631-871-1811
NOT Certification Perry Farms _ NOT.pdf 295.77KB
Form Mist be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification En -ails
(Optional)

Original Permittee CCd on Klotification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]