NCC191513_Notice of Termination_20201112

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/12/2020 10:22:58 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/13/2020 7:28:29 AM (NOT Request Review- NCC191513)
• The task was assigned to Georgoulias, Bethany. The due date is: November 17, 2020 5:00 PM
11/12/2020 10:23 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191513
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Lexington Starbucks
Address
77 Plaza Parkway, Lexngton, NC
County
Davidson
Latitude
35.7830
Longitude
-80.2570
Permittee Listed
Lexington Parkway Plaza, LLC
Legally Responsible
Clay Coyle
Individual
NC Reference No.
NCG01-2019-1513
E&SC Plan ID
David-2020-012
Original NOI
15104
Tracking No.
Date COC Issued
8/26/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 4/27/2020
Inspection Approval

Project Close-out 04-22-2020 Closure Inspection Report (DAVID-
Approval 27.62KB
2020-012).pdf
Documentation
NCG01-eNOT-Certification-Form-20190508-
259.6KB
DEMLR-SW - Complete.pdf
Mist be PDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
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 of the
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* Clay Coyle
Title * Managing Agent
Organization* Lexington Parkway Plaza, LLC
Date * 11 /12/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 7049272896
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form 259.6KB
DEMLR-SW - Complete.pdf
Must be R F Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]