NCC191759_Notice of Termination_20201117

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/17/2020 3:47:06 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/18/2020 8:20:46 AM (NOT Request Review- NCC191759)
• The task was assigned to Georgoulias, Bethany. The due date is: November 20, 2020 5:00 PM
11/17/2020 3:47 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191759
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Knightdale Medical Office Building
Address
1101 Great Falls Ct, Knightdale, NC
County
Wake
Latitude
36.0000
Longitude
-78.0000
Permittee Listed
Great Falls Owners LLC
Legally Responsible
Robert S. Adams
Individual
NC Reference No.
NCG01-2019-1759
E&SC Plan ID
SEC-021386-2019
Original NOI
15641
Tracking No.
Date COC Issued
9/11/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 6/3/2020
Inspection Approval

Project Close-out Certificate of Completion_SECO21386-2019 -
Approval 118.99KB
Knightdale MOB.pdf
Documentation
Mast be FL7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
document filed 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 under this Article; or who falsifies, tampers with, or knowinglyrenders
inaccurate any recording 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 may include 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
wmt !. yp4v,111
Type Name* Robert S. Adams, III
Title * Member/Manager
Organization* Great Falls Owners, LLC
Date * 11 /17/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-289-1338
NOT Certification NGC01 Notice of Termination - Knightdale MOB.pdf 21.08KB
Form Mast be PDF Forrrst
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 Notificaiton Errails
Email [e-mail]