NCC192635_Notice of Termination_20201208

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/8/2020 9:45:02 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/9/2020 9:20:33 AM (NOT Request Review- NCC192635)
• The task was assigned to Georgoulias, Bethany. The due date is: December 11, 2020 5:00 PM
12/8/2020 9:45 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC192635
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee
OPEN
Status
Information associated
with this permit:
Project Name
18020CUL
Address
388 Talbert Road, Mooresville, NC
County
Iredell
Latitude
35.5834
Longitude
-80.8519
Permittee Listed
BUILD Carolina, LLC
Legally Responsible
AJ Bremerman
Individual
NC Reference No.
NCG01-2019-2635
E&SC Plan ID
MVLLE-2020-027
Original NOI
17999
Tracking No.
Date COC Issued
11/4/2019
Prior Rescission
Cute populates only if CCCwas already rescinded at tirre of submttal.
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 *
r Mistake or Invalid Coverage
r Other
Addional IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcurrentation if applicable.
Documentation NLstbeFOFformat
Project Close-out Information:

Final Close-out 8/3/2020
Inspection Approval
Project Close-out 18020CUL MVLLE-2020-027 8-3-20.pdf 564KB
Approval Mast be FCFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Pnyperson 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 of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to e)ceed ten thousand
dollars ($10,000).
rJ 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* AJ Bremerman
Title * Vice Presisdent
Organization* BUILD Carolina, LLC
Date * 12/08/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 12395949984
NOT Certification NOT-NOI.Mooresville.pdf 533.02KB
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification BTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]