NCC190086_Notice of Termination_20201025

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/25/2020 1:44:49 PM (NOT Submittal)
Approve by Georgoulias, Bethany 10/26/2020 8:22:25 AM (NOT Request Review- NCC190086)
• The task was assigned to Georgoulias, Bethany. The due date is: October 29, 2020 5:00 PM
10/25/2020 1:44 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190086
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
Information associated
with this permit:
Project Name
CW Performance Auto
Address
1751 Pinnacle Center Drive, Apex, NC
County
Wake
Latitude
35.7185
Longitude
-78.8238
Permittee Listed
Bern Development, Inc.
Legally Responsible
Charles Vollmer
Individual
NC Reference No.
NCG01-2019-0086
E&SC Plan ID
18-020
Original NOI
10314
Tracking No.
Date COC Issued
4/23/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 10/8/2020
Inspection Approval

Project Close-out Scan_0224.pdf 366.01KB
Approval Mast be FDFforrrat
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
"Vd4UW_1_
Type Name* Charles Vollmer
Title * Chairman of the Board
Organization* Bern Development, Inc.
Date * 10/25/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-427-2572
NOT Certification Scan_0225.pdf 409.1KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Errails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton B mils
Email [e-mail]