NCC192629_Notice of Termination_20201124

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/24/2020 3:33:46 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/30/2020 8:09:08 AM (NOT Request Review- NCC192629)
• The task was assigned to Georgoulias, Bethany. The due date is: November 27, 2020 5:00 PM
11 /24/2020 3:33 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192629
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
7-Eleven #41126
Address
1440 Greensboro Rd, High Point, NC
County
Guilford
Latitude
35.9906
Longitude
-79.9572
Permittee Listed
C4 CStore Holdings, LLC
Legally Responsible
Timothy Sittema
Individual
NC Reference No.
NCG01-2019-2629
E&SC Plan ID
EN1902742278
Original NOI
17991
Tracking No.
Date COC Issued
11/12/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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 10/16/2020
Inspection Approval

Project Close-out 41126 Erosion Control Close Out.pdf 393.42KB
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
�A46 {PY ! d r FA +
Type Name* Timothy Sittema
Title * Manager
Organization* C4 CStore Holdings, LLC
Date * 11 /24/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919.610.7875
NOT Certification NCG01-eNOT-Certification-Form-20190508-
Form 223.3KB
DEMLR-SW.pdf
Mast be PM Format
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 Kbtificaiton Bmils
Email [e-mail]