NCC190872_Notice of Termination_20201130

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/30/2020 9:57:51 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/30/2020 2:59:51 PM (NOT Request Review- NCC190872)
• The task was assigned to Georgoulias, Bethany. The due date is: December 3, 2020 5:00 PM
11/30/2020 9:58 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190872
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Panera Bread
Address
1911 North Main Street, High Point, NC
County
Guilford
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
CCT High Point, LLC
Legally Responsible
Brad Copp
Individual
NC Reference No.
NCG01-2019-0872
E&SC Plan ID
EN1901262268
Original NOI
13177
Tracking No.
Date COC Issued
7/9/2019
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Date populates only if OOCwas already rescinded at tirre of subaittal.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
Add ional Nbre inforrration about the basis of this request, if needed.
Explanation Project completed
Supporting upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 11/19/2020
Inspection Approval

Project Close-out Erosion Control & Surety Release - High Point
Approval 4.76MB
Panera 11-24--20.pdf
Documentation
Mast be FL7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, 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 knowingly renders
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 guilty ofa 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
Type Name* Doug Compton
Title * Manager
Organization* CCT High Point, LLC
Date * 11 /30/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 513-784-0010
NOT Certification Notice of Termination Certification Form.pdf 290.91 KB
Form Mast be PDF Forr at
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 Errails
Email [e-mail]