NCC190916_Notice of Termination_20210401

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/1/2021 4:40:21 PM (NOT Submittal)
Approve by Morman, Alaina 4/6/2021 8:31:12 AM (NOT Request Review- NCC190916)
• The task was assigned to Morman, Alaina. The due date is: April 6, 2021 5:00 PM 4/1/2021 4:40 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190916
Coverage (COC) Enter the Certificate of Coverage Nimber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status Nbybeblank (if not yet billed)
Information associated with this permit:
Project Name
NC Hwy 55 Self -Storage Center
Address
2117 NC Hwy 55, White Oak, NC
County
Wake
Latitude
36.0000
Longitude
-79.0000
Permittee Listed
919 Storage NC 55 LLC
Legally Responsible
Mike Karpinski
Individual
NC Reference No.
NCG01-2019-0916
E&SC Plan ID
S-6061
Original NOI
13300
Tracking No.
Date COC Issued
7/11/2019
Prior Rescission
Cate populates only if CCCwas already rescinded at tirre of subrrittal.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 obtained 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 Docurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 3/8/2021
Inspection Approval
Project Close-out S006061 Certificate of Completion _NC HWY 55
Approval 136.11 KB
SELF -STORAGE CENTER.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
Type Name* Mike Karpinski
Title * VP of Development
Organization* 919 Storage NC 55 LLC
Date * 04/01 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 3173398302
NOT Certification NCG01-eNOT-Certification-Form-20210305-
Form DEMLR-SW SIGNED MK 040121.pdf
Mast be R F Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
845.12KB