HomeMy WebLinkAboutNCC190845_Notice of Termination_20201111Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/11/2020 10:44:11 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/12/2020 8:07:23 AM (NOT Request Review- NCC190845)
Permittee omitted NOT Certification form but provided it via e-mail on 11/11.
• The task was assigned to Georgoulias, Bethany. The due date is: November 16, 2020 5:00 PM
11/11/2020 10:44 AM
1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190845
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
Information associated with this permit
Project Name
BURGER KING RESTAURANT
Address
923 GATEWAY COMMONS CIRCLE, WAKE FOREST, NC
County
Wake
Latitude
35.9683
Longitude
-78.4967
Permittee Listed
PROSTRUCTION, INC.
Legally Responsible
KURT HENDRICKSON
Individual
NC Reference No.
NCG01-2019-0845
E&SC Plan ID
2019-00000142
Original NOI
13080
Tracking No.
Date COC Issued
7/3/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 12/17/2019
Inspection Approval
Project Close-out Burger King Letter of Completion LDP 2019-
Approval 122.16KB
0142.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
�}tirrt�, rr 'ryr°A'�tci;�.iGYf
Type Name* Kurt M. Hendrickson
Title * President
Organization* Prostruction, inc.
Date * 11 /11 /2020
Email for kurt@prostructioninc.com
Confirmation *
Contact Telephone* 9198722299
NOT Certification Burger King Letter of Completion LDP 2019-
Form 122.16KB
0142. pdf
Mist be RY Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee 0Cd on Wification Errails
Email KURT@PROSTRUCTIONINC.COM
Original Site Contact CCd on %tificaiton Bmils
Email KURT@PROSTRUCTIONINC.COM