NCC191287_Notice of Termination_20200428

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/28/2020 9:43:50 AM (NOT Submittal)
Approve by Georgoulias, Bethany 4/28/2020 10:57:40 AM (NOT Request Review- NCC191287)
• The task was assigned to Georgoulias, Bethany. The due date is: May 1, 2020 5:00 PM
4/28/2020 9:43 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191287
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Dollar General Lexington
Address
E US Hwy 64, Lexington, NC
County
Davidson
Latitude
35.8776
Longitude
-80.3186
Permittee Listed
Teramore Construction
Legally Responsible
Zach Crumley
Individual
NC Reference No.
NCG01-2019-1287
E&SC Plan ID
David-2020-008
Original NOI
14639
Tracking No.
Date COC Issued
8/9/2019
Prior Rescission
Date populates only if OOCwas already rescinded at tirre of subaittal.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * O Mistake or Invalid Coverage
r Other
Addional We inforrration about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 4/22/2020
Inspection Approval

Project Close-out 04-22-2020 Closure Inspection Report (DAVID-
Approval 27.84KB
2020-008).pdf
Documentation
Mast be FDFforrrat
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 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 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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 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
Zaoi C'.t"
Type Name* Zach Crumley
Title * Senior VP
Organization* Teramore Construction
Date * 04/28/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 912-312-4610
NOT Certification Signed NOT Certification Form_Letangton.pdf 308.9KB
Form Mast be PDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since submttal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]