NCC192504_Notice of Termination_20210125

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/25/2021 8:24:32 AM (NOT Submittal)
Approve by Morman, Alaina 1/28/2021 8:58:17 AM (NOT Request Review- NCC192504)
• The task was assigned to Morman, Alaina. The due date is: January 28, 2021 5:00 PM
1 /25/2021 8:24 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192504
Coverage (COC) Enter the Certificate of Coverage Ninber
No.*
2020 Annual Fee Status PAST DUE
2021 Annual Fee Status Nbybeblank (if not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Reviewstep) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Firestone @ Bryton Town Center
Address
10348 Cane Creek Drive, Huntersville, NC
County
Mecklenburg
Latitude
35.3722
Longitude
-80.8306
Permittee Listed
Rock Huntersville, LLC
Legally Responsible
Gregg Zuckerman
Individual
NC Reference No.
NCG01-2019-2504
E&SC Plan ID
EPW383726
Original NOI
17627
Tracking No.
Date COC Issued
10/25/2019
Prior Rescission
Cate populates only if CDC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
C Project Closed -Out
Termination of
Q Sale (Another Owner/Operator will apply for a new COC)
Coverage *
a Mistake or Invalid Coverage
0 Other

Add ional Nbre infornation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting DDcurrentation if applicable.
Documentation Mist beFDFforrat
Project Close-out Information:
Final Close-out 1/15/2021
Inspection Approval
Project Close-out Firestone Huntersville Storm Water Permit
Approval #383726.pdf
Documentation
Firestone Huntersville Certificate of Coverage.pdf
Town of Huntersville Final Inspection Report.pdf
Mist be FDFforr at
North Carolina General Statute 143-215.66 (1) provides that:
41.7KB
36.81 KB
172.12KB
Any person who knowinglymakes anyfalse statement, representation, or certification in anyapplication, record, report, plan, or other
document filed 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 under this Arficle; or who 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 may include 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
�9�rrrrr����r�.�r•
Type Name* Gregg Zuckerman
Title * Manager
Organization* Rock Huntersville, LLC
Date * 01 /25/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 4074788220
NOT Certification Signed NOT Certification Form.pdf 341.98KB
Form Mist be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?

Additional Email GCd on Notification BTails
(Optional)
Original Permittee GCdonNlotificationBTails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]