NCC200657_Notice of Termination_20210317

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/17/2021 4:58:08 PM (NOT Submittal)
Approve by Morman, Alaina 3/18/2021 6:21:12 PM (NOT Request Review- NCC200657)
• The task was assigned to Morman, Alaina. The due date is: March 22, 2021 5:00 PM
3/17/2021 4:58 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200657
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
fvby be blank (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 Review step) 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
Sanctuary at Yates Mill subdivision, Lot 32
Address
2312 Sanctuary Drive, Raleigh, NC
County
Wake
Latitude
35.7169
Longitude
-78.7319
Permittee Listed
Medallion Construction Inc.
Legally Responsible
Barney Baxter
Individual
NC Reference No.
NCG01-2020-0657
E&SC Plan ID
SEC-032362
Original NOI
22050
Tracking No.
Date COC Issued
2/19/2020
Prior Rescission
Cate populates only if OOCwas already rescinded at tirre of subaittal.
Date
Reason for Rescission/Termination Request:

Reason for IT Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a newCOC)
Coverage * r Mistake or Invalid Coverage
f Other
Add ional
Mxe information about the basis of this request, if needed.
Explanation
House completed and SOLD LAST year. I'm
submnitting here the Certif of Completion.
WHY doesn't it state what the specific form
you want is???
Supporting
Upload Supporting Dxurrentation if applicable.
Documentation
Mast beFCFformat
Project Close-out Information:
Final Close-out 10/28/2020
Inspection Approval
Project Close-out Certificate of Completion.pdf 115.77KB
Approval Mast be FDFformat
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 Atcle; 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 Atcle shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to e)ceed 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* Barney Baxter
Title * President
Organization* Medallion Construction
Date * 03/17/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 19193493325

NOT Certification NoticeofTerminationLot32Sanctuary.pdf 46.22KB
Form Mist be Ft7F Format
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee 0Cd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Emils
Email [e-mail]