NCC191170_Notice of Termination_20210809

Action History (UTC-05:00) Eastern Time(US&Canada)
Submit by Anonymous User 8/9/2021 2:14:12 PM(NOT Submittal)
Approve by Morman,Alaina 8/11/2021 3:12:46 PM(NOT Request Review-NCC191170)
• The task was assigned to Morman,Alaina.The due date is:August 12,2021 5:00 PM
8/9/2021 2:14 PM

" 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 NCC191170
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 Dollar General-Linwood#20827
Address Old Salisbury Road, Salisbury, NC
County Davidson
Latitude 35.7358
Longitude -80.3768
Permittee Listed Teramore Construction
Legally Responsible Zach Crumley
Individual
NC Reference No. NCG01-2019-1170
E&SC Plan ID David-2019-030
Original NOI 14242
Tracking No.
Date COC Issued 7/31/2019
Prior Rescission Cate populates only if COC was already rescinded at time of submittal.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 8/5/2021
Inspection Approval
Project Close-out Inspection Report 08-05-21 (DAVID-2020-003).pdf 135.56KB
Approval Mast 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* Zach Crumley
Title* Senior VP
Organization* Teramore Construction
Date* 08/09/2021
Email for [e-mail]
Confirmation
Contact Telephone* 2295164289
NOT Certification NOT_Linwood.pdf 384.72KB
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on%tificaiton Errails
Email [e-mail]

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