NCC203227_Notice of Termination_20240719

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 7/19/2024 10:30:31 AM (NOT Submittal)
Approve by Kieu Tran 7/23/2024 1:17:40 PM (NOT Request Review-NCC203227)
• The task was assigned to DEMLR NCG01 NOT Review Team.The due date is:July 24,2024 5:00 PM
7/19/2024 10:30:31 AM
• The task was assigned to Kieu Tran by round robin distribution 7/19/2024 10:30:31 AM

NPDE,�tz-
Stormwater Permit for . •
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 NCG010000(or NCG250000). If approved,the Certificate of Coverage
(COC)will be rescinded.
Certificate of NCC203227
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 PAID PAID
May be blank if N/A May be blank if N/A
2023 Annual Fee Status 2024 Annual Fee Status COC Expiration Date
PAID OPEN 3/31/2029
May be blank if N/A May be blank if N/A
This permittee has an OPEN fee. If this NOT request is acceptable,you will have the option to waive that fee, but that is
only available AFTER the Notice of Termination(NOT)has been approved(when the permit status becomes INACTIVE).
If it is appropriate to waive the OPEN fee,it may help to assign that annual fee task to yourself immediately following this
approval so you remember to resolve the outstanding fee.
Information associated with this permit:
Project Name Tanglewood Forest 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 4161 Clinard Road,Clemmons, NC
County Forsyth
Latitude 36.0110
Longitude -80.3933
Permittee Listed 4161 Clinard Road, LLC
Legally Responsible John Kennedy
Individual
NC Reference No. NCG01-2020-3227
E&SC Plan ID EN2000029
Original NOI Tracking 28925
No.
Date COC Originally Most Recent Prior Rescission Date?(If
Issued Issuance/Renewal Date Applicable)
07/29/2020 04/01/2024 Checked again at Review Step
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
Supporting Upload Supporting Documentation if applicable.
Documentation Must be PDF format
Project Close-out Information:
Erosion Control Plan 5/13/2024
Close-out Date
Erosion Control Plan 5-13-2024 inspection.pdf 80.53KB
Close-out Must be PDF format
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
.�lk-�N"Y
Type Name* John K Kennedy
Title* member manager
Organization* 4161 Clinard Road LLC
Date* 07/19/2024
Email for [e-mail]
Confirmation*
Contact Telephone* 3363995213
NOT Certification Signed Notice of Termination NCC203227.pdf 200.31 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]