NCC190335_Notice of Termination_20210331

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/31/2021 5:18:49 PM (NOT Submittal)
Approve by Morman, Alaina 4/5/2021 2:38:51 PM (NOT Request Review- NCC190335)
• The task was assigned to Morman, Alaina. The due date is: April 5, 2021 5:00 PM 3/31/2021 5:18 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190335
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
PAID
2021 Annual Fee Status
Nbybeblank (if not yet billed).
Information associated
with this permit:
Project Name
The Gables at Bridgton Sec 3, Ph2
Address
Gabel Drive, Winston Salem, NC
County
Forsyth
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Pennston Corp.
Legally Responsible
Bruce Hubbard
Individual
NC Reference No.
NCG01-2019-0335
E&SC Plan ID
EN1900073
Original NOI
11201
Tracking No.
Date COC Issued
5/21/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained 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 Docurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 12/15/2020
Inspection Approval
Project Close-out NCGO1 Notice of Termination (NOT) Certification
Approval 587.94KB
Form-GatB,sec3,ph 2 - 3-31-2021 (2).pdf
Documentation
Mist 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 Article or a rule implementing this Article; or who knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording 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 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
��ew��td
Type Name* Bruce R. Hubbard
Title * Vice President
Organization* Pennston Corp
Date * 03/31 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-403-3092
NOT Certification NCGO1 Notice of Termination (NOT) Certification
Form 56.68KB
Form-GatB,sec3,ph 2 - 3-31-2021.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact OCd on %tificaiton Errails
Email [e-mail]