NCC200636_Notice of Termination_20210624

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/24/2021 11:35:30 AM (NOT Submittal)
Approve by Morman, Alaina 6/25/2021 3:30:32 PM (NOT Request Review- NCC200636)
• The task was assigned to Morman, Alaina. The due date is: June 29, 2021 5:00 PM
6/24/2021 11:35 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200636
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 193
Address
620 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.
NCG01-2020-0636
E&SC Plan ID
SEC-031042-2020
Original NOI
22025
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Cate populates only if COCwas already rescinded at time of submittal.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 6/18/2021
Inspection Approval
Project Close-out Lot 193 Certificat of
Approval 133.04KB
Completeion_SEC_31042_2020. 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* Kimberly Walters
Title * President
Organization* Stellar Blu Construction, Inc
Date * 06/24/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 19193451924
NOT Certification NCG01-eNOT-Certification-Form-20210514-
Form DEMLR-SW Signed.pdf
Mist be FDF Format
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 BTails
Email [e-mail]
987.43KB