NCC200987_Notice of Termination_20210405

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/5/2021 10:45:52 AM (NOT Submittal)
Approve by Morman, Alaina 4/6/2021 3:51:21 PM (NOT Request Review- NCC200987)
• The task was assigned to Morman, Alaina. The due date is: April 8, 2021 5:00 PM 4/5/2021 10:45 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200987
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Carlton Pointe Phase 3B, Lot 85
Address
Prides Crossing, Rolesville, NC
County
Wake
Latitude
35.9047
Longitude
-78.4753
Permittee Listed
ICG Homes, LLC
Legally Responsible
Ryan Perry
Individual
NC Reference No.
NCG01-2020-0987
E&SC Plan ID
SEC-030803-2019
Original NOI
23024
Tracking No.
Date COC Issued
3/13/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.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 *
r Mistake or Invalid Coverage
r Other
Addional Nbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation NtastbeRYforrrat

Project Close-out Information:
Final Close-out 11/5/2020
Inspection Approval
Project Close-out CPT085 - SEC-030803-2019 Certificate of
Approval 163.33KB
Completion_Lot85_11-5-20 (1).pdf
Documentation
Mist be FDFforrrat
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 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 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
Type Name* Ryan Perry
Title * Owner
Organization* ICG Homes, LLC
Date * 04/05/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 8033481944
NOT Certification CPT085 - NCG01 NOT Cert Form.pdf 642.62KB
Form Mist be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
CCd on Notification Bmils
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]