NCC230832_Notice of Termination_20240307

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Anonymous User 3/7/2024 1:24:08 PM(NOT Submittal)
Approve by Kieu Tran 3/15/2024 11:51:03 AM (NOT Request Review-NCC230832)
• The task was assigned to DEMLR NCG01 NOT Review Team.The due date is: March 12,2024 5:00
PM 3/7/2024 1:24:09 PM
• The task was assigned to Kieu Tran by round robin distribution 3/7/2024 1:24:09 PM

Q� Notice of Termination (NOT) Request - NPDE,�tz_
Stormwater Permit for . •
Use this form to submit a Notice of Termination(NOT)request for a project covered under the N.C.NPDES
General Permit for Construction Activities NCG010000(or NCG250000). If approved,the Certificate of Coverage
(COC)will be rescinded.
Certificate of NCC230832
Coverage(COC)No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
May be blank if N/A May be blank if N/A May be blank if N/A
2023 Annual Fee Status 2024 Annual Fee Status
May be blank if N/A May be blank if N/A
Information associated with this permit:
Project Name Propel LLC Commercial Building Site 101007
Lots Covered by this This information is especially helpful when more lots were added with Modifications since the original permit
Permit COC(if issuance.
applicable) No longer visible on the initial form(data not captured from initial application)
Address Parcel ID#101700 North Highway 16, Denver, NC
County Lincoln
Latitude 35.5380
Longitude -81.0420
Permittee Listed Propel LLC
Legally Responsible Damon Lusk
Individual
NC Reference No. NCG01-2023-0832
E&SC Plan ID 23-COM-01
Original NOI Tracking 132923
No.
Date COC Issued 4/14/2023
Prior Rescission Date Date populates only if COC was already rescinded at time of submittal.
Reason for Rescission/Termination Request:
Reason for Project Closed-Out
Termination of Sale(Another Owner/Operator obtained new COC)
Coverage* Mistake or Invalid Coverage
Other
New owner/operator NCC240660
COC No. Enter the COC number obtained by the new owner

New Owner Name First and last name
Bill Zemak
New Owner Phone [phone]
Number
New Owner Email [e-mail]
Additional More information about the basis of this request,if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation NCG01 Notice of Termination Propel LLC
842.92KB
NCC230832 March 7 2023.pdf
Must be PDF format
Project Close-out Information:
Erosion Control Plan
Close-out Date
Erosion Control Plan Must be PDF format
Close-out
Documentation
North Carolina General Statute 143-215.613(i)provides that:
Any person who knowingly makes any false 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 device or method required to be operated or maintained under this Article or rules of the Commission implementing this Article shall
be guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars($10,000).
* 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 ����
0W.'"r 16-J.f
Type Name* Damon Lusk
Title* Managing Member
Organization* Propel LLC
Date* 03/07/2024
Email for [e-mail]
Confirmation*
Contact Telephone* 704-578-3404

NOT Certification NOT Form Propel LLC NCC230832.pdf 251.66KB
Form Must be PDF Format
Is this COC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emai!s
(Optional) [e-mail]
Original Permittee CC'd on Notification Emai!s
Email [e-mail]
Original Site Contact CC'd on Notificaiton Emai!s
Email [e-mail]