NCC190548_Notice of Termination_20201222

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 12/22/2020 9:41:56 AM (NOT Submittal)
Approve by Georgoulias, Bethany 12/22/2020 11:32:25 AM (NOT Request Review- NCC190548)
The annual fee has been waived, and the NOD is resolved.
• The task was assigned to Georgoulias, Bethany. The due date is: December 25, 2020 5:00 PM
12/22/2020 9:41 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190548
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status WAIVED
2021 Annual Fee Status
N/A
Information associated
with this permit:
Project Name
Circle K - R&R 2723778
Address
2219 Jefferson Davis Highway, Raleigh, NC
County
Lee
Latitude
35.4390
Longitude
-79.2170
Permittee Listed
Circle K Stores, Inc
Legally Responsible
Will Rice
Individual
NC Reference No.
NCG01-2019-0548
E&SC Plan ID
LEE-2019-007
Original NOI
11910
Tracking No.
Date COC Issued
6/10/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
U 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 5/6/2020
Inspection Approval
Project Close-out 2410 - Circle K #3778 - Close Out Report.pdf 35.6KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) 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 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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to 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
Af CG
Type Name* Will Rice
Title * Division Vice President
Organization * Circle K Stores, Inc.
Date * 12/22/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 2529465175
NOT Certification 2410 - NOT Certification Form - For Signature.pdf 124.41 KB
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Erails
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]