NCC192350_Notice of Termination_20211005

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/5/2021 3:31:32 PM (NOT Submittal)
Approve by Morman, Alaina 10/11/2021 4:12:15 PM (NOT Request Review- NCC192350)
• The task was assigned to Morman, Alaina. The due date is: October 8, 2021 5:00 PM
10/5/2021 3:31 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192350
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
Woodleaf Dollar General #20477
Address
8790 Woodleaf Road, Woodleaf, NC
County
Rowan
Latitude
35.7672
Longitude
-80.5895
Permittee Listed
Teramore Construction, LLC
Legally Responsible
Zach Crumley
Individual
NC Reference No.
NCG01-2019-2350
E&SC Plan ID
Dollar General, Woodleaf NC
Original NOI
17121
Tracking No.
Date COC Issued
10/16/2019
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Cate populates only if COCwas already rescinded at time of submittal.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 10/4/2021
Inspection Approval
Project Close-out Sedimentation Inspection Report Dollar General -
Approval 266.69KB
Woodleaf 10.04.2021.pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed 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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which may include 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, LLC
Date * 10/05/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 229-516-4289
NOT Certification NOT Certification Letter_Woodleaf.pdf
Form Mast be PDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
382.36KB