NCC190559_Notice of Termination_20201104

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/4/2020 3:53:49 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/5/2020 8:03:44 AM (NOT Request Review- NCC190559)
• The task was assigned to Georgoulias, Bethany. The due date is: November 9, 2020 5:00 PM
11 /4/2020 3:53 PM

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NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190559
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Store #20302 Lincolnton, NC Dollar General
Address
2639 N Aspen Street, Lincolnton, NC
County
Lincoln
Latitude
35.5047
Longitude
-81.2400
Permittee Listed
Teramore Development, LLC
Legally Responsible
Zach Crumley
Individual
NC Reference No.
NCG01-2019-0559
E&SC Plan ID
19-COM-04
Original NOI
11960
Tracking No.
Date COC Issued
6/10/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 11/3/2020
Inspection Approval

Project Close-out DOC110320-002.pdf
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
463.09KB
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording 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 notto 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* Zach Crumley
Title * Senior VP
Organization* Teramore Development
Date * 11 /04/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 229-516-0246
NOT Certification NOT Form _Lincolnton DG.pdf 340.94KB
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 Notificaiton Bmils
Email [e-mail]