NCC200327_Notice of Termination_20200615

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/15/2020 11:53:50 AM (NOT Submittal)
Approve by Georgoulias, Bethany 6/16/2020 8:52:17 AM (NOT Request Review- NCC200327)
• The task was assigned to Georgoulias, Bethany. The due date is: June 18, 2020 5:00 PM
6/15/2020 11:53 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200327
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Fuquay Varina Dollar General
Address
8909 US 401 North, Fuquay Varina, NC
County
Harnett
Latitude
35.5114
Longitude
-78.8139
Permittee Listed
Par 5 Development Group, LLC
Legally Responsible
Jody Bland
Individual
NC Reference No.
NCG01-2020-0327
E&SC Plan ID
HARNE-2019-096
Original NOI
21111
Tracking No.
Date COC Issued
1/28/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 6/9/2020
Inspection Approval

Project Close-out Fuquay Varina NC DEQ Inspection Report 6-9-
Approval 20.pdf 57.33KB
Documentation
Mast be FL7Fforrrat
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
�Jk X- &
Type Name* Joseph K. Bland
Title * Vice President
Organization* Par 5 Development Group, LLC
Date * 06/15/2020
Email for [e-mail]
Confirmation *
Contact Telephone* [phone]
NOT Certification NCC200327 Signed Notice of Termination
Form 358.71 KB
Certification Form.pdf
Wst be RY Format
Is this COC Already Ensure this CCChas not been rescinded since submttal!
Rescinded?
Original Permittee CCd on Wif ication Bi ails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]