NCC193234_Notice of Termination_20201019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/19/2020 11:28:26 AM (NOT Submittal)
Approve by Georgoulias, Bethany 10/19/2020 1:23:30 PM (NOT Request Review- NCC193234)
• The task was assigned to Georgoulias, Bethany. The due date is: October 22, 2020 5:00 PM
10/19/2020 11:28 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC193234
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Rheem Distribution Center Building Expansion
Address
4744 Island Ford Road, Randleman, NC
County
Randolph
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Samet Corporation
Legally Responsible
Arthur Samet
Individual
NC Reference No.
NCG01-2019-3234
E&SC Plan ID
RANDO-2020-007
Original NOI
19648
Tracking No.
Date COC Issued
12/20/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.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
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 10/13/2020
Inspection Approval

Project Close-out Inspection Report 10-13-20 (RANDO-2020-007).pdf 134.17KB
Approval Mist be RYfornil
Documentation
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
Type Name* Mitchell Sisco
Title * Superintendent
Organization* Samet Corporation
Date * 10/19/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 3362638010
NOT Certification NCG01 Notice of Termination (NOT) Certification
Form 368.01 KB
Form COMPLETE 10-19-20.pdf
Mast be R F Format
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]