NCC190419_Notice of Termination_20210720

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 7/20/2021 11:27:34 AM(NOT Submittal)
Approve by Morman,Alaina 7/21/2021 9:05:58 AM(NOT Request Review-NCC190419)
• The task was assigned to Morman,Alaina.The due date is:July 23,2021 5:00 PM
7/20/2021 11:27 AM

" RequestNOT • Construction Stormwater
1 i
�a•aThis formto request Notice of • • for •co\erage under •
NORTH CAROLINA General - for • i i• Activities Qr�arrry
Certificate of NCC190419
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status PAID
May be blank(if not yet billed).
Information associated with this permit:
Project Name Circle K-R&R 2723046
Address 674 Chicken Foot Road, Hope Mills, NC
County Cumberland
Latitude 34.9350
Longitude -78.9210
Permittee Listed Circle K Stores, Inc.
Legally Responsible Will Rice
Individual
NC Reference No. NCG01-2019-0419
E&SC Plan ID CUMBE-2019-046
Original NOI 11566
Tracking No.
Date COC Issued 5/31/2019
Prior Rescission Cate populates only if COC was already rescinded at time of submittal.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 7/16/2021
Inspection Approval
Project Close-out Circle K R&R 2723046 NCDENR Final Inspection-
Approval 36.95KB
Approved.pdf
Documentation
Mist be FDFforrrat
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* Meredith W. Rice
Title* Vice President
Organization* Circle K Stores, Inc.
Date* 07/20/2021
Email for \[e-mail]
Confirmation
Contact Telephone* 919-995-0843
NOT Certification CK R&R 2723046 NOT 19JUL202107-19-2021-
Form 234.01 KB
144748.pdf
Must be FDF Fbrnat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email \[e-mail]
Original Site Contact 0Cd on Notificaiton Frrails
Email [e-mail]