NCC191442_Notice of Termination_20201124

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/24/2020 11:41:52 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/30/2020 8:02:10 AM (NOT Request Review- NCC191442)
• The task was assigned to Georgoulias, Bethany. The due date is: November 27, 2020 5:00 PM
11 /24/2020 11:42 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191442
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Premier Stores, Inc
Address
4826 W Wendover Ave, High Point, NC
County
Guilford
Latitude
36.0456
Longitude
-79.9280
Permittee Listed
Premier Stores, Inc
Legally Responsible
Phil Kleinman
Individual
NC Reference No.
NCG01-2019-1442
E&SC Plan ID
EN-19-0125
Original NOI
14950
Tracking No.
Date COC Issued
8/20/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 8/20/2020
Inspection Approval

Project Close-out receiptView.do.pdf 85.47KB
Approval Surety Release Letter.pdf 1.46MB
Documentation
Mast be FL7Fforrrat
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* Phil Kleinman
Title * President
Organization* Premier Stores, Inc
Date * 11 /24/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 3368510568
NOT Certification NOT Form.pdf 604.91KB
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wif ication Bi ails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]