NCC190705_Notice of Termination_20210526

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/26/2021 3:43:35 PM (NOT Submittal)
Approve by Morman, Alaina 5/28/2021 9:22:11 AM (NOT Request Review- NCC190705)
• The task was assigned to Morman, Alaina. The due date is: May 31, 2021 5:00 PM 5/26/2021 3:43 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190705
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
Middleburg Dollar General
Address
Bullocksville Park Road, Middleburg, NC
County
Vance
Latitude
36.4591
Longitude
-78.3102
Permittee Listed
Par 5 Development Group, LLC
Legally Responsible
Rudy Lee Pittman
Individual
NC Reference No.
NCG01-2019-0705
E&SC Plan ID
VANCE-2019-004
Original NOI
12735
Tracking No.
Date COC Issued
6/24/2019
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.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 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 Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 5/24/2021
Inspection Approval
Project Close-out VANCE-2019-004_20210524_lnspRpt.pdf 1.54MB
Approval Mast be FDFfornat
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
Type Name* Rudy Lee Pittman
Title * Member/Manager
Organization * Par 5 Development Group, LLC
Date * 05/26/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 910-944-0881
NOT Certification Manson NC Signed NOT - NCC190705.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 CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
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