NCC220427_Notice of Termination_20220124

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/24/2022 12:31:21 PM (NOT Submittal)
Approve by Morman, Alaina 1/24/2022 4:36:23 PM (NOT Request Review - NCC220427)
• The task was assigned to Morman, Alaina. The due date is: January 27, 2022 5:00 PM
1/24/202212:31 PM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC220427
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status
2021 Annual Fee Status 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
Cliffdale Woods Subdivision - SFD lots
Address
Bismarck Court, Winston Salem, NC
County
Forsyth
Latitude
36.0946
Longitude
-80.3119
Permittee Listed
Clayton Properties Group Inc dba Shugart Homes
Legally Responsible
Connie Ader
Individual
NC Reference No.
NCG01-2022-0427
E&SC Plan ID
EN2000112
Original NOI Tracking
78907
No.
Date COC Issued
1/21/2022
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Date populates only if COC was already rescinded at time of submittal.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
Additional More information about the basis of this request, if needed.
Explanation NC Reference No. NCG01-2022-0427

Supporting Upload Supporting Documentation if applicable.
Documentation termination reference email for COC.pdf
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:
277.17KB
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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
Type Name* Connie Ader
Title* Operations Manager
Organization* Clayton Properties Group Inc dba Shugart Homes
Date * 01 /24/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 336-823-0275
NOT Certification Cliffdale Woods COC NCC2204727 termination.pdf 70.2KB
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) [e-mail]
Original Permittee CC'd on Notification Emails
Email [e-mail]

Original Site Contact cc'd on Notificaiton Emails
Email [e-mail]