NCC201469_Notice of Termination_20200414

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 4/14/2020 2:37:58 PM (NOT Submittal)
Approve by Georgoulias, Bethany 4/15/2020 7:51:49 AM (NOT Request Review- NCC201469)
p Applicant notified us about this discrepancy and wanted to terminate/reapply. Entity will apply for
another COC for this project.
• The task was assigned to Georgoulias, Bethany. The due date is: April 17, 2020 5:00 PM
4/14/2020 2:38 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201469
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Colony Tire
Address
2460 Gillespie St, Fayetteville, NC
County
Cumberland
Latitude
35.0148
Longitude
-79.8977
Permittee Listed
BBC of Edenton, LLC
Legally Responsible
Andrew Bergeron
Individual
NC Reference No.
NCG01-2020-1469
E&SC Plan ID
CUMBE-2020-115
Original NOI
24235
Tracking No.
Date COC Issued
4/14/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 * F Mistake or Invalid Coverage
r Other
Add ional We information about the basis of this request, if needed.
Explanation Incorrect Owner name should be BCC of
Edenton, LLC in lieu of 'BBC'
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFfornat
Project Close-out Information:

Final Close-out
Inspection Approval
Project Close-out Mast bePDFfornat
Approval
Documentation
North Carolina General Statute 143-215.613 (i) 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 Artide; 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 device 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 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* Andrew Bergeron
Title * Member Manager
Organization * BCC of Edenton, LLC
Date * 04/14/2020
Email for [e-mail]
Confirmation *
Contact Telephone* [e-mail]
NOT Certification NCG01 Notice of Termination (NOT).pdf
Form Mast be RY Fbrrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]
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