NCC190524_Notice of Termination_20201103

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/3/2020 9:18:52 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/5/2020 7:34:25 AM (NOT Request Review- NCC190524)
* J. Banks provided revised NOT Certification Form with date via e-mail on 1114.
• The task was assigned to Georgoulias, Bethany. The due date is: November 6, 2020 5:00 PM
11 /3/2020 9:19 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190524
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
FCS Facility
Address
3350 Holabird Lane, Charlotte, NC
County
Mecklenburg
Latitude
35.2104
Longitude
-80.9149
Permittee Listed
3021 Nesbitt Dr. LLC
Legally Responsible
Patrick Faulkner
Individual
NC Reference No.
NCG01-2019-0524
E&SC Plan ID
LDGP-2019-00107
Original NOI
11839
Tracking No.
Date COC Issued
6/6/2019
Prior Rescission
Date populates only if OOC was already rescinded at tirre of subaittal.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 10/27/2020
Inspection Approval

Project Close-out 201027 City of Charlotte - Grading Notice of
Approval 85.5KB
Termination.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
Type Name* Patrick Faulkner
Title * Manager
Organization* 3021 Nesbitt Dr., LLC
Date * 11 /03/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 7043198141
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form 243.53KB
DEMLR-SW (003).pdf
Mist be RY 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 Kbtificaiton Brails
Email [e-mail]