NCC190813_Notice of Termination_20201116

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/16/2020 10:16:07 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/16/2020 11:07:20 AM (NOT Request Review- NCC190813)
• The task was assigned to Georgoulias, Bethany. The due date is: November 19, 2020 5:00 PM
11/16/2020 10:16 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190813
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
Information associated with this permit
Project Name
O'Reilly Auto Parts; High Point, NC #1
Address
2406 South Main Street, High Point, NC
County
Guilford
Latitude
35.9303
Longitude
-79.9888
Permittee Listed
O'Reilly Automotive Stores, Inc.
Legally Responsible
Scott Kraus
Individual
NC Reference No.
NCG01-2019-0813
E&SC Plan ID
EN1802102274
Original NOI
12995
Tracking No.
Date COC Issued
7/2/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 7/27/2020
Inspection Approval

Project Close-out Surety Release EN 19 0210 2274 7-2020.pdf 15.34MB
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
Type Name* Scott Kraus
Title * SVP Real Estate and Expansion
Organization* O'Reilly Automotive Stores, Inc.
Date * 11 /16/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 4178662741
NOT Certification 11 16 20 NOT Certification Form (HP1).pdf
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]
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