NCC192526_Notice of Termination_20211012

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/12/2021 10:33:55 AM (NOT Submittal)
Approve by Morman, Alaina 10/12/2021 1:59:01 PM (NOT Request Review- NCC192526)
• The task was assigned to Morman, Alaina. The due date is: October 15, 2021 5:00 PM
10/12/2021 10:34 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192526
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
Commercial Truck Center and Storage Building Mass Grading
Address
4291 Papa Joe Hendrick Blvd, Charlotte, NC
County
Cabarrus
Latitude
35.3596
Longitude
-80.7038
Permittee Listed
HSREI LLC A NC LLC
Legally Responsible
A. Scott Ennis
Individual
NC Reference No.
NCG01-2019-2526
E&SC Plan ID
CABAR-2020-020
Original NOI
17631
Tracking No.
Date COC Issued
10/28/2019
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Cate populates only if COCwas already rescinded at time of submittal.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 9/2/2021
Inspection Approval
Project Close-out #1 CABAR-2020-020 NCDEQ Final Inspection.pdf 46.83KB
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
u�.�rrri
Type Name* Scott Ennis
Title * Vice President
Organization * Hendrick Automotive Group
Date * 10/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704-566-3268
NOT Certification COT Truck Center and Storage Building - NCG01
Form Notice of Termination Certification Form 62.69KB
(Grading).pdf
Mast be FDF Format
Is this COC Already Ensure this COChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCd on Wification Errails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]