NCC190631_Notice of Termination_20191126

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/21/2019 8:48:32 AM (NOT Submittal)
Approve by Georgoulias, Bethany 11/27/2019 7:29:42 AM (NOT Request Review- NCC190631)
p Applicant did not upload NOT Certification form with the initial submittal. The reviewer requested and
received it via e-mail, and will add it to the final record. Also, the original NOI indicated the wrong county
for this project (Guilford instead of Alamance). The reviewer will correct the metadata for all the records to
identify Alamance Co.
• McCoy, Suzanne reassigned the task to Georgoulias, Bethany 11/21/2019 2:05 PM
• The task was assigned to McCoy, Suzanne by round robin distribution 11/21/2019 8:48 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: November 26, 2019 5:00
PM 11 /21 /2019 8:48 AM

1 �
NORTH CAROLINA
Enrlronmenral quallly
Certificate of NCC190631
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Andy's Frozen Custard
Address
Huffman Mill Rd, Burlington, NC
County
Guilford
Latitude
36.0770
Longitude
-79.4920
Permittee Listed
Qualified Builders, Inc
Legally Responsible
Ryan Marsh
Individual
NC Reference No.
NCG01-2019-0631
E&SC Plan ID
002140-002
Original NOI
12431
Tracking No.
Date COC Issued
6/17/2019
Prior Rescission
This field will populate only ff OOChas already been rescinded.
Date
Reason for Rescission/Termination Request:
Reason for F Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * O Mistake or Invalid Coverage
r Other
Addional We inforrration about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFforrrat
Project Close-out Information:
Final Close-out 11/14/2019
Inspection Approval

Project Close-out NPDES LETTER11202019.pdf 700.2KB
Approval Mist be RYfornil
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording or monitoring deice or method required to be operated or maintained under this Article or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine notto exceed ten thousand
dollars ($10,000).
17 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* Terry Smith
Title * Sr. Project Manager
Organization* Qualified Builders, Inc.
Date * 11 /21 /2019
Email for [e-mail]
Confirmation *
Contact Telephone* 919-784-9280
NOT Certification NPDES LETTER11202019.pdf 700.2KB
Form Mist be FDF Forrrat