NCC192696_Notice of Termination_20210202

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/2/2021 9:18:28 AM (NOT Submittal)
Approve by Morman, Alaina 2/4/2021 4:45:13 PM (NOT Request Review- NCC192696)
On 21412021, Joseph Alm from Gaston County confirmed this project never commenced.
• The task was assigned to Morman, Alaina. The due date is: February 5, 2021 5:00 PM
2/2/2021 9:18 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192696
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
Chick-fil-A#0856 Franklin Square
Address
3350 East Franklin Blvd., City of Gastonia, NC
County
Gaston
Latitude
35.0000
Longitude
-81.0000
Permittee Listed
Chick-fil-A, INC.
Legally Responsible
Evan Foster
Individual
NC Reference No.
NCG01-2019-2696
E&SC Plan ID
000000246
Original NOI
18195
Tracking No.
Date COC Issued
11/12/2019
Prior Rescission
Cate populates only if CDC was already rescinded at tirre of submittal.
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
F Other project cancelled

Add ional We information about the basis of this request, if needed.
Explanation Project never commenced - cancelled
Supporting upload Supporting Docurrentation if applicable.
Documentation NCG01-eNOT-Certification-Form-20201215-
DEMLR-SW.pdf
Mast be FDFforr at
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mast beFDFfornat
Approval
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
894.61 KB
Any person who knowingly makes anyfalse statement, representation, or certification in any application, 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 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 may include a fine not to exceed ten thousand
dollars ($10,000).
17 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
[ r41yl dC.rr�-
Type Name* Evan Foster
Title * Project Manager
Organization* Chick-fil-A, Inc.
Date * 02/02/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 770-842-9758
NOT Certification NCG01-eNOT-Certification-Form-20201215-
Form 894.61 KB
DEMLR-SW.pdf
Mast be FDF Fornat
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?

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