NCC190943_Notice of Termination_20201209

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/9/2020 9:51:12 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/9/2020 2:31:23 PM (NOT Request Review- NCC190943)
p DEQ DEMLR inspection report included.
• The task was assigned to Georgoulias, Bethany. The due date is: December 14, 2020 5:00 PM
12/9/2020 9:51 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190943
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee
OPEN
Status
Information associated
with this permit:
Project Name
Harris Teeter Fuel # 139- Colours
Address
2000 Waterscape Way, New Bern, NC
County
Craven
Latitude
35.0000
Longitude
-77.0000
Permittee Listed
Buskirk Construction, Inc.
Legally Responsible
Peter Buskirk
Individual
NC Reference No.
NCG01-2019-0943
E&SC Plan ID
Crave-2019-037
Original NOI
13411
Tracking No.
Date COC Issued
7/12/2019
Prior Rescission
Cute populates only if CCCwas already rescinded at time of submittal.
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 No inspection was ever done
Supporting upload Supporting Documentation if applicable.
Documentation IvLstbeFOFforrrat
Project Close-out Information:

Final Close-out 8/6/2020
Inspection Approval
Project Close-out 200806 HARRIS TETTER FUEL CRAVE-2019-
Approval 31.9KB
037FinalStormwaterinspect.pdf
Documentation
Mist be FL7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Arficle; orwho 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 Arficle shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto 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* Peter S Buskirk
Title * President
Organization* Buskirk Construction, Inc.
Date * 12/09/2020
Email for [e-mail]
Confirmation *
Contact Telephone * 910 520 3507
NOT Certification 200806 HARRIS TETTER FUEL CRAVE-2019-
Form 31.9KB
037FinalStormwaterinspect.pdf
Wst be Ft7F 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 Kbtificaiton Bmils
Email [e-mail]