NCC200261_Notice of Termination_20210729

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 7/29/2021 8:05:36 AM (NOT Submittal)
Approve by Morman, Alaina 7/29/2021 2:40:21 PM (NOT Request Review- NCC200261)
• The task was assigned to Morman, Alaina. The due date is: August 3, 2021 5:00 PM
7/29/2021 8:05 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200261
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
Clemmons Medical Office
Address
3311 Jessie Village Dr., Clemmons, NC
County
Forsyth
Latitude
36.0407
Longitude
-80.3900
Permittee Listed
OC-DMC, LLC
Legally Responsible
Austin Koon
Individual
NC Reference No.
NCG01-2020-0261
E&SC Plan ID
EN1900163
Original NOI
20933
Tracking No.
Date COC Issued
1/23/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 5/13/2021
Inspection Approval
Project Close-out OC - Grading Inspection Report - Notice of
Approval 151.68KB
Termination.pdf
Documentation
OC Clemmons Certificate of Occupancy.pdf 63.19KB
NCG01-NOT form.pdf 275.86KB
#20-107 Clemmons Medical Office —Occupancy
93.41 KB
Permit.pdf
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 of the
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* Austin Koon
Title * Manager
Organization* OC-DMC, LLC
Date * 07/29/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9192019378
NOT Certification NCG01-NOT form.pdf 275.86KB
Form Mist be PDF 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 CCdonNotificationBmils
Email [e-mail]
Original Site Contact GCd on Notificaiton BTails
Email [e-mail]