NCC202092_Notice of Termination_20210530

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/30/2021 2:16:01 PM (NOT Submittal)
Approve by Morman, Alaina 6/3/2021 10:43:51 AM (NOT Request Review- NCC202092)
• The task was assigned to Morman, Alaina. The due date is: June 3, 2021 5:00 PM 5/30/2021 2:16 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC202092
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
fvby be blank (if not yet billed).
Information associated
with this permit:
Project Name
Garner Plaza SC, LLC
Address
3210 Sanderford Road, Garner, NC
County
Wake
Latitude
35.7351
Longitude
-78.6071
Permittee Listed
Jesucristo Fuente De Amor Y Vida
Legally Responsible
Robert Knowles
Individual
NC Reference No.
NCG01-2020-2092
E&SC Plan ID
SEC-032576-2020
Original NOI
25667
Tracking No.
Date COC Issued
5/19/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
r Mistake or Invalid Coverage
F Other FRO change for current work
Addional
We information about the basis of this request, if needed.
Explanation
New NCG01 for shared work on 3210
Sanderford with recently issued COC
NCC213021

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mast beFDFforrrat
Approval
Documentation
North Carolina General Statute 143-215.613 (i) 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 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 mayinclude 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
Type Name* Rodolfo Olivo
Title * President
Organization * Jesucristo Fuente de Amor y Vida
Date * 05/30/2021
Email for davidt.lane@_zoho.com
Confirmation *
Contact Telephone* 9843283010
NOT Certification Notice of Termination Jesucristo.pdf 9.31 MB
Form Mast be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
CCd on Notification Brails
davidt.lane@_zoho.com

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]