NCC190213_Notice of Termination_20201208

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/8/2020 11:02:03 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/10/2020 10:53:15 AM (NOT Request Review- NCC190213)
p Close-out inspection document provided via e-mail on 12110. Annual fee has been waived and NOD is
resolved.
• The task was assigned to Georgoulias, Bethany. The due date is: December 11, 2020 5:00 PM
12/8/2020 11:02 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190213
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee WAIVED
Status
Information associated with this permit:
Project Name
Firestone @ Harrisburg Town Center
Address
Kee Lane, Harrisburg, NC
County
Cabarrus
Latitude
35.3236
Longitude
-80.6450
Permittee Listed
Rock Harrisburg, LLC
Legally Responsible
Gregg Zuckerman
Individual
NC Reference No.
NCG01-2019-0213
E&SC Plan ID
CABAR-2019-086
Original NOI
10758
Tracking No.
Date COC Issued
5/8/2019
Prior Rescission
Cute populates only if CCCwas already rescinded at tirre of subnittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
F 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 Documentation if applicable.
Documentation 17165 NCG01-eNOT-Certification-Form-20190508-
601.11 KB
DEMLR-SW, 12082020.pdf
Deed.pdf 237.32KB
Mast be FDFformat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mast beFDFforrrat
Approval
Documentation
North Carolina General Statute 143-215.6B (i) 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 Prtide; 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 device 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 exceed ten thousand
dollars ($10,000).
fJ 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
l' Il Zk4WAU&
Type Name* Gregg Zuckerman
Title * Manager
Organization* Rock Harrisburg, LLC
Date * 12/08/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 407-478-8220
NOT Certification 17165 NCG01-eNOT-Certification-Form-20190508-
Form 601.11 KB
DEMLR-SW, 12082020.pdf
Mast be FDF Fornat
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Original Permittee CCdonWificationEmails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]