NCC190790_Notice of Termination_20210520

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/20/2021 1:23:53 PM (NOT Submittal)
Approve by Morman, Alaina 5/23/2021 12:42:04 PM (NOT Request Review- NCC190790)
• The task was assigned to Morman, Alaina. The due date is: May 25, 2021 5:00 PM 5/20/2021 1:24 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190790
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
PAID
2021 Annual Fee Status
Nbybeblank (if not yet billed).
Information associated
with this permit:
Project Name
Circle K - R&R 2720481
Address
3458 N. Main Street, Hope Mills, NC
County
Cumberland
Latitude
34.9758
Longitude
-78.9511
Permittee Listed
Circle K Stores Inc
Legally Responsible
Will Rice
Individual
NC Reference No.
NCG01-2019-0790
E&SC Plan ID
CUMBE-2019-150
Original NOI
12910
Tracking No.
Date COC Issued
7/1/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
F Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
O 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 5/17/2021
Inspection Approval
Project Close-out Circle K R&R 2720481 - Final Inspection Report.pdf 29.16KB
Approval 2720481 Approval Email.pdf 208.85KB
Documentation
Mist be Ft7Fforrrat
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
(WI �'1:4 1; V�rct
Type Name* Meredith Will Rice
Title * Vice President
Organization* Circle K
Date * 05/20/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 919-995-0843
NOT Certification 2720481 NOT for DEQ - Signed.pdf
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCdonNotificationBails
Email \[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
492.26KB