NCC200449_Notice of Termination_20210330

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/30/2021 2:46:29 PM (NOT Submittal)
Approve by Morman, Alaina 4/5/2021 10:16:17 AM (NOT Request Review- NCC200449)
• The task was assigned to Morman, Alaina. The due date is: April 2, 2021 5:00 PM 3/30/2021 2:47 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200449
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
ivby be blank (if not yet billed).
Information associated with this permit:
Project Name
Pine Forest II
Address
Amity Hill Rd., Statesville, NC
County
Iredell
Latitude
35.7399
Longitude
-80.8685
Permittee Listed
JGNC ll, LLC
Legally Responsible
Anita Johnson
Individual
NC Reference No.
NCG01-2020-0449
E&SC Plan ID
STVLE-2020-011
Original NOI
21522
Tracking No.
Date COC Issued
2/5/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
f Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
F Other Sale (Another Owner/Operator obtained new COC)
Addional IVbre information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation MTS Pine Forest, II - deed.pdf
Certificate of Coverage_MTS Pine Forest, LLC.pdf
NUst be FDFformat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFforrrat
Approval
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
609.56KB
36.13KB
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 of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
I7 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* Anita R. Johnson
Title * Member - Manager
Organization* JGNC, LLC
Date * 03/30/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7049961195
NOT Certification Signed _Pine Forest II NOT —Sediment Ersion Control
Form (JGNC, LLC).pdf 1.13MB
Mist be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)

Original Permittee CCdonNotificationEn-ails
Email [e-mail]
Original Site Contact GCd on Notificaiton Erails
Email [e-mail]