NCC205214_Notice of Termination_20210930

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 9/30/2021 12:13:57 PM (NOT Submittal)
Approve by Morman, Alaina 10/4/2021 9:17:44 PM (NOT Request Review- NCC205214)
• The task was assigned to Morman, Alaina. The due date is: October 5, 2021 5:00 PM
9/30/2021 12:14 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC205214
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
Arcadia Ridge
Address
Central Road, Clemmons, NC
County
Davidson
Latitude
35.9850
Longitude
-80.2988
Permittee Listed
Clayton Properties Group Inc
Legally Responsible
Ken Capron
Individual
NC Reference No.
NCG01-2020-5214
E&SC Plan ID
DAVID-2021-016
Original NOI
35836
Tracking No.
Date COC Issued
11/13/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
U Mistake or Invalid Coverage
r Other
Additional Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 9/21/2021
Inspection Approval
Project Close-out Inspection Report 09-21-21 (DAVID-2021-016).pdf 127.25KB
Approval Mast be FDFforrrat
Documentation
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* Ken Capron
Title * Land Acquisition Manager
Organization * Clayton Properties Group, Inc DBA Shugart Homes
Date * 09/30/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-624-3359
NOT Certification NOT.pdf 70.36KB
Form Mast 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]