NCC191919_Notice of Termination_20200518

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/18/2020 4:14:51 PM (NOT Submittal)
Approve by Georgoulias, Bethany 5/19/2020 12:37:18 PM (NOT Request Review- NCC191919)
• The task was assigned to Georgoulias, Bethany. The due date is: May 21, 2020 5:00 PM
5/18/2020 4:14 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191919
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Hendersonville Panera Bread
Address
160 Coolridge St., Hendersonville, NC
County
Henderson
Latitude
35.3356
Longitude
-82.4482
Permittee Listed
PB Hendersonville CGP, LLC
Legally Responsible
National Registered Agents Inc.
Individual
NC Reference No.
NCG01-2019-1919
E&SC Plan ID
2019-01-06
Original NOI
15932
Tracking No.
Date COC Issued
9/18/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of subrrittal.
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
Add ional
We information about the basis of this request, if needed.
Explanation
Henderson County has issued an email
confirming permanent stability and has
asked that we file the NOT.
Supporting
Upload Supporting Docurrentation if applicable.
Documentation
Mist beFDFforrrat
Project Close-out Information:

Final Close-out 5/12/2020
Inspection Approval
Project Close-out Inspection_Report_15_06_09_05_12_20.pdf 102.17KB
Approval Mast be PDFforrrat
Documentation
North Carolina General Statute 143-215.613 (i) 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 Artide; 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 device or method required to be operated or maintained under this Article or rules of the
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
,T,2es Z Fay-Y-&'�
Type Name* James K Farrelly
Title * Director of Engineering
Organization* Capital Growth Buchalter, Inc.
Date * 05/18/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 2052634589
NOT Certification Notice of Termination (NOT) Certification Form -
Form 649.55KB
Panera.pdf
Mast be PDF Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Nutificaiton Errails
Email [e-mail]