NCC200639_Notice of Termination_20210504

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/4/2021 6:30:35 AM (NOT Submittal)
Approve by Georgoulias, Bethany A 5/4/2021 11:16:18 AM (NOT Request Review- NCC200639)
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 5/4/2021 11:07 AM
The task was assigned to Morman, Alaina. The due date is: May 7, 2021 5:00 PM 5/4/2021 6:30 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200639
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
Nt3y be blank (if not yet billed).
Information associated with this permit:
Project Name
Stonewater Subdivision, Phase 5 Lot 171
Address
717 Pelzer Dr, Wake Forest, NC
County
Wake
Latitude
35.9304
Longitude
-78.4984
Permittee Listed
Stellar Blu Construction, Inc
Legally Responsible
Kimberly Walters
Individual
NC Reference No.
NCG01-2020-0639
E&SC Plan ID
SEC-031039-2020
Original NOI
22001
Tracking No.
Date COC Issued
2/19/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation Mist beRYforrrat

Project Close-out Information:
Final Close-out 4/30/2021
Inspection Approval
Project Close-out Lot 171_SEC-031039-2020_Certificate of
Approval 134.47KB
Completion_ 4-30-21.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 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
Type Name* Kimberly Walters
Title * President
Organization* Stellar Blu Construction, Inc
Date * 05/04/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9193451924
NOT Certification NCG01-eNOT-Signed_Lot171.pdf
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
980.01 KB