NCC203799_Notice of Termination_20211004

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/4/2021 9:05:05 AM (NOT Submittal)
Approve by Morman, Alaina 10/11/2021 10:23:09 AM (NOT Request Review- NCC203799)
• The task was assigned to Morman, Alaina. The due date is: October 7, 2021 5:00 PM
10/4/2021 9:05 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC203799
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
fvhy be blank (if not yet billed).
Information associated with this permit:
Project Name
Idolwood
Address
6751 Idols Road, Clemmons, NC
County
Forsyth
Latitude
36.0034
Longitude
-80.3786
Permittee Listed
Idolwood LLC
Legally Responsible
James Blakley
Individual
NC Reference No.
NCG01-2020-3799
E&SC Plan ID
398818
Original NOI
30655
Tracking No.
Date COC Issued
9/2/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
f Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other Sale (Another Owner/Operator obtained new COC)
Additional Nbre inforrration about the basis of this request, if needed.
Explanation Request Close Out.
Sold in March 2021 to new owner. New
owner has grading permits and COC No.

Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mast beFDFforrrat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFfornat
Approval
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 Artide or a rule implementing this Artide; 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 a)Ceed 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* James Blakley
Title * Manager
Organization* Idolwood
Date * 10/04/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 336-817-2273
NOT Certification NCG01 - NOT Form.pdf 33.89KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]