NCC190536_Notice of Termination_20210707

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/7/2021 9:42:40 AM (NOT Submittal)
Approve by Morman, Alaina 7/8/2021 9:17:11 AM (NOT Request Review- NCC190536)
• The task was assigned to Morman, Alaina. The due date is: July 12, 2021 5:00 PM 7/7/2021 9:42 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC190536
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
PAID
2021 Annual Fee Status
OPEN
K/hy be blank (if not yet billed).
Information associated
with this permit:
Project Name
Hardee's Shallotte
Address
4414 Main St, Shallotte, NC
County
Brunswick
Latitude
33.9856
Longitude
-78.3648
Permittee Listed
Bay Foods Inc.
Legally Responsible
Reggie Barnacascel
Individual
NC Reference No.
NCG01-2019-0536
E&SC Plan ID
BRUNS-2019-072
Original NOI
11871
Tracking No.
Date COC Issued
6/7/2019
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
r Mistake or Invalid Coverage
r Other
Addional IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation Mist beRYforrrat

Project Close-out Information:
Final Close-out 7/15/2020
Inspection Approval
Project Close-out Hardee's Shallotte - 7.15.20.pdf 135.25KB
Approval Must be FDFforrrat
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 under this 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 of the
Commission implementing this Artcle 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* Reggie Barnacascel
Title * Senior Director of Construction
Organization* Bay Foods Inc.
Date * 07/07/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9196693798
NOT Certification NCG01 Notice of Termination Form_Shallotte
Form Signed.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this OCChas not been rescinded since subrrittal!
Rescinded?
Additional Email OCd 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]
343.24KB