NCC192716_Notice of Termination_20210104

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/4/2021 11:13:16 AM (NOT Submittal)
Approve by Georgoulias, Bethany 1/4/2021 11:18:48 AM (NOT Request Review- NCC192716)
• The task was assigned to Georgoulias, Bethany. The due date is: January 7, 2021 5:00 PM
1/4/2021 11:13 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC192716
Coverage (COC)
Enter the Certificate of Coverage Namber
No.*
2020 Annual Fee Status OPEN
2021 Annual Fee Status
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Krispy Kreme Stratford Road
Address
259 South Stratford Road, Winston-Salem, NC
County
Forsyth
Latitude
36.0919
Longitude
-80.2806
Permittee Listed
Krispy Kreme Doughnut Corporation
Legally Responsible
David Milne
Individual
NC Reference No.
NCG01-2019-2716
E&SC Plan ID
326727
Original NOI
18194
Tracking No.
Date COC Issued
11/12/2019
Prior Rescission
Date populates only if COCwas already rescinded at tirre of subrrittal.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 *
r Mistake or Invalid Coverage
r Other Project did not begin after permit received
Addional
We information about the basis of this request, if needed.
Explanation
David Milne is no longer with Krispy Kreme.
Levi Hetrick will be signing the NOT.
Supporting
Upload Supporting Docurrentation if applicable.
Documentation
Mast beFDFformat

Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFforrrat
Approval
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
Lr.Vi �1
Type Name* Levi Hetrick
Title * Vice President, Shop Experience & Real Estate
Organization* KrispyKreme
Date * 01 /04/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704-778-0080
NOT Certification NCG01 NOT _KrispyKreme_2021-01-04.pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton 57ails
Email frank. [e-mail]
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