NCC191375_Notice of Termination_20201215

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/15/2020 9:54:07 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/15/2020 11:00:57 AM (NOT Request Review- NCC191375)
• The task was assigned to Georgoulias, Bethany. The due date is: December 18, 2020 5:00 PM
12/15/2020 9:54 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191375
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status N/A
Information associated with this permit
Project Name
Denver ABC Store
Address
N. NC #16 Business Highway, Denver, NC
County
Lincoln
Latitude
35.5188
Longitude
-81.0046
Permittee Listed
Lincoln County ABC Board
Legally Responsible
Marty Mull
Individual
NC Reference No.
NCG01-2019-1375
E&SC Plan ID
LINCO-2020-005
Original NOI
14815
Tracking No.
Date COC Issued
8/15/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
O Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 11/17/2020
Inspection Approval
Project Close-out Ir_silt_sedementation_inspection_report_modifiedP...
Approval 36.12KB
(5) -Close Out Inspection Report.pdf
Documentation
Mast be FDFforrrat
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 Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording 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 notto exceed 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
" Hq
Type Name* Marty Mull
Title * Chairman
Organization * Lincoln County ABC Board
Date * 12/15/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 7044832286
NOT Certification NOTICE OF TERMINATION (NOT) CERTIFICATION
Form 74.29KB
FORM.pdf
Mast be RY Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email 0Cd on Notification Errails
(Optional) [e-mail]
Original Permittee 0Cd on Wification E rrails
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]