NCC193160_Notice of Termination_20201007

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/7/2020 3:39:06 PM (NOT Submittal)
Approve by Georgoulias, Bethany 10/8/2020 8:48:28 AM (NOT Request Review- NCC193160)
• The task was assigned to Georgoulias, Bethany. The due date is: October 12, 2020 5:00 PM
10/7/2020 3:39 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC193160
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
QT1082
Address
19807 Burton Lane, Cornelius, NC
County
Mecklenburg
Latitude
35.4844
Longitude
-80.8722
Permittee Listed
QuikTrip
Legally Responsible
Paulette Morin
Individual
NC Reference No.
NCG01-2019-3160
E&SC Plan ID
378015
Original NOI
19244
Tracking No.
Date COC Issued
12/12/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 9/30/2020
Inspection Approval

Project Close-out QT Cornelius Final.pdf
Approval Mist be RYfornil
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
102.49KB
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
Type Name* Colin Potter
Title * Construction Manager
Organization* QuikTrip Corporation
Date * 10/07/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 520-548-6877
NOT Certification SKM_C454e20100715510.pdf 66.9KB
Form Mist be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since submttal!
Rescinded?
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]