NCC191578_Notice of Termination_20210914

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/14/2021 3:08:11 PM (NOT Submittal)
Approve by Morman, Alaina 9/19/2021 12:50:50 PM (NOT Request Review- NCC191578)
• The task was assigned to Morman, Alaina. The due date is: September 17, 2021 5:00 PM
9/14/2021 3:08 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191578
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
2021 Annual Fee Status OPEN
Nby be blank (if not yet billed).
Information associated with this permit:
Project Name
State Employees' Credit Union Brier Creek Branch
Address
7800 T.W. Alexander Dr, Raleigh, NC
County
Wake
Latitude
35.9199
Longitude
-78.7778
Permittee Listed
J. D. Beam, Inc.
Legally Responsible
Tom Antoine
Individual
NC Reference No.
NCG01-2019-1578
E&SC Plan ID
528413-445053-LD-120368
Original NOI
15259
Tracking No.
Date COC Issued
9/20/2019
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Cate populates only if COCwas already rescinded at time of submittal.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
Additional 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 5/26/2021
Inspection Approval
Project Close-out SR-11-2017 CERTIFICATE OF COMPLETION.pdf 95.02KB
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
7UW you
Type Name* Thomas Antoine
Title * President
Organization* J.D. Beam, Inc.
Date * 09/14/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 19196756965
NOT Certification NOT - NCC191578.pdf 110.39KB
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
CCd on Notification Bmils
[e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]