NCC192671_Notice of Termination_20200303

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/3/2020 2:36:36 PM (NOT Submittal)
Approve by Clark, Paul 3/3/2020 2:48:14 PM (NOT Request Review- NCC192671)
. The task was assigned to Clark, Paul by round robin distribution 3/3/2020 2:36 PM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: March 6, 2020 5:00 PM
3/3/2020 2:36 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC192671
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name Brier Creek Medical Office
Address 7901 ACC Blvd, Raleigh, NC
County Wake
Latitude 35.9170
Longitude-78.7790
Permittee Listed VNSN, LLC
Legally Responsible Vinod Jindal
Individual
NC Reference No. NCG25-2019-2671
E&SC Plan ID SPR-0058-2019
Original NOI 18130
Tracking No.
Date COC Issued 11/12/2019
Prior Rescission Date populates only if OOCwas already rescinded at tirre of subaittal.
Date
Reason for Rescission/Termination Request:
Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator will apply for a new COC)
Coverage * r Mistake or Invalid Coverage
F Other replaced with NCC200263
Addional We information 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
Inspection Approval

Project Close-out Mast beFDFformat
Approval
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 underthis 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 mayinclude a fine not to 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* Vinod Jindal
Title * Owner
Organization* VNSN, LLC
Date * 03/03/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 2524920028
NOT Certification BC signed NOT_03032020142603.PDF 20.33KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?