NCC200326_Notice of Termination_20200415

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/15/2020 4:02:28 PM (NOT Submittal)
Approve by Georgoulias, Bethany 4/16/2020 7:47:06 AM (NOT Request Review- NCC200326)
• The task was assigned to Georgoulias, Bethany. The due date is: April 20, 2020 5:00 PM
4/15/2020 4:02 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200326
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Dollar General Mintonsville
Address
NC Hwy 32, Mintonsville, NC
County
Gates
Latitude
36.3488
Longitude
-76.6362
Permittee Listed
Glandon Forest Equity
Legally Responsible
George Barnes
Individual
NC Reference No.
NCG01-2020-0326
E&SC Plan ID
Gates-2020-002
Original NOI
21031
Tracking No.
Date COC Issued
1/24/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
r Mistake or Invalid Coverage
r Other Project not granted rezoning
Addional
We information about the basis of this request, if needed.
Explanation
Supporting
Upload Supporting Lbcurrentation if applicable.
Documentation
DG Mintonsville Inspection .pdf 60KB
Mast be FOFforrrat
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* George Barnes
Title * Member/Manager
Organization* Glandon Forest Equity
Date * 04/15/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-459-2601
NOT Certification Dollar General Mintonsville NOT.pdf
Form Mast be RY Forrrat
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]
42.67KB