NCC200847_Notice of Termination_20220120

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/20/2022 3:49:14 PM (NOT Submittal)
Approve by Morman, Alaina 1/24/2022 2:59:56 PM (NOT Request Review - NCC200847)
• The task was assigned to Morman, Alaina. The due date is: January 25, 2022 5:00 PM
1/20/2022 3:49 PM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC200847
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status
2021 Annual Fee Status PAID
May be blank (if not yet billed).
2022 Annual Fee May be blank (if not yet billed).
Status
Information associated with this permit
Project Name
Harden Creek
Address
Wendell Road, Archer Lodge, NC
County
Johnston
Latitude
36.0000
Longitude
-78.0000
Permittee Listed
Cloudbreak Investments, LLC
Legally Responsible
Nathan Evans
Individual
NC Reference No.
NCG01-2020-0847
E&SC Plan ID
JC#19-136-P
Original NOI Tracking
22640
No.
Date COC Issued
3/4/2020
Prior Rescission Date
Date populates only if COC was already rescinded at time of submittal.
Reason for Rescission/Termination Request:
Reason for Project Closed -Out
Termination of Sale (Another Owner/Operator obtained new COC)
Coverage* Mistake or Invalid Coverage
Other
New ownerloperator NCC217139
COC No. Enter the COC number obtained by the new owner

New Owner Name
New Owner Phone
Number
First and last name
JSJ Builders
9103090119
New Owner Email [e-mail]
Additional More information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation scan0573 (2).pdf 1.97MB
Must be PDF format
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Must be PDF format
Approval
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document
filed 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 under this Article; or who falsifies, tampers with, or knowingly renders inaccurate any recording
or monitoring device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* 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* Janie Murray
Title * Bookkeeper
Organization* Cloudbreak Investments LLC
Date * 01 /20/2022
Email for [e-mail]
Confirmation *
Contact Telephone* 9192797924
NOT Certification scan0622.pdf 760.56KB
Form Must be PDF Format

Is this COC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emails
(Optional)
Original Permittee CC'd on Notification Emails
Email [e-mail]
Original Site Contact CC'd on Notificaiton Emails
Email [e-mail]