NCC217019_Notice of Termination_20220526

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/26/2022 4:07:19 PM (NOT Submittal)
Approve by Clark, Paul B 6/1/2022 1:15:22 PM (NOT Request Review - NCC217019)
F Note - EN2100225 is the number on E&SC plan approval and close out report. These are consistent.
Yet a different number = 635906 put in application and on COC.
• The task was assigned to Clark, Paul B by round robin distribution 5/26/2022 4:07 PM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: May 31, 2022 5:00 PM
5/26/2022 4:07 PM

Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCGO10000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC217019
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
May be blank if N/A May be blank if N/A May be blank if N/A
Information associated with this permit
Project Name Sadie Valley Subdivision
Lots Covered by this This information is especially helpful when more lots were added with Modifications since the original permit
Permit COC (if
issuance.
applicable)
No longer visible on the initial form (data not captured from initial application)
Address
0 Moore Road, Tobaccoville, NC
County
Forsyth
Latitude
36.2534
Longitude
-80.3464
Permittee Listed
Adam Stewart
Legally Responsible
Adam Stewart
Individual
NC Reference No.
NCG01-2021-7019
E&SC Plan ID
635906
Original NOI Tracking
75926
No.
Date COC Issued
12/20/2021
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Date populates only if COC was already rescinded at time of submittal.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 See attached report
Additional More information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation SV Docs.pdf 503.81 KB
Must be PDF format
Project Close-out Information:
Erosion Control Plan
Close-out Date
Erosion Control Plan Must be PDF format
Close-out
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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
Type Name* Adam N. Stewart
Title* Owner
Organization * Sadie Valley Subdivision
Date * 05/26/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 3365361047
NOT Certification NOT Cert.pdf 279.11 KB
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]