NCC201804_Notice of Termination_20210525

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/25/2021 4:10:29 PM (NOT Submittal)
Approve by Morman, Alaina 5/28/2021 5:41:59 PM (NOT Request Review- NCC201804)
• The task was assigned to Morman, Alaina. The due date is: May 28, 2021 5:00 PM 5/25/2021 4:10 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201804
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
K/hy be blank (if not yet billed).
Information associated with this permit:
Project Name
4010 Mendenhall Oaks Parkway
Address
4010 Mendenhall Oaks Parkway, High Point, NC
County
Guilford
Latitude
36.0440
Longitude
-79.9620
Permittee Listed
4008 Mendenhall Oaks, LLC
Legally Responsible
Will Stevens
Individual
NC Reference No.
NCG01-2020-1804
E&SC Plan ID
EN 20 0078 2303
Original NOI
25018
Tracking No.
Date COC Issued
5/6/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 MstbeRYforrrat

Project Close-out Information:
Final Close-out 1/19/2021
Inspection Approval
Project Close-out Land -disturbing permit closure - 4010 Mendenhall 673.06KB
Approval Oaks Parkway05252021.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* William Stevens, III
Title * Manager
Organization* 4008 Mendenhall Oaks, LLC
Date * 05/25/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 3365805977
NOT Certification NCG01 -Termination Certificate Form - 4010
Form 490.92KB
MOP05252021.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
OCd on Notification Errails
[e-mail]
CCd on Notification Erails
[e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]