NCC202592_Notice of Termination_20200730

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/30/2020 11:50:06 AM (NOT Submittal)
Approve by Georgoulias, Bethany 7/30/2020 1:34:28 PM (NOT Request Review- NCC202592)
• The task was assigned to Georgoulias, Bethany. The due date is: August 4, 2020 5:00 PM
7/30/2020 11:50 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC202592
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Addison Fifteen 20
Address
8255 Old Holland Rd, Charlotte, NC
County
Cabarrus
Latitude
35.0000
Longitude
-81.0000
Permittee Listed
Addison Concord, LLC
Legally Responsible
John Schaffer
Individual
NC Reference No.
NCG01-2020-2592
E&SC Plan ID
cabar-2020-048
Original NOI
27060
Tracking No.
Date COC Issued
6/22/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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
F Other Name Change
Add ional
We information about the basis of this request, if needed.
Explanation
New Certification Issued under new project
name: NCC203255
Supporting
upload Supporting Lbcurrentation if applicable.
Documentation
NCG01-eNOT-Certification-Form-executed.pdf 631.71KB
Mast be FDF format
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* John Schaffer
Title * Manager
Organization* Addison Concord, LLC
Date * 07/30/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 407-333-0066
NOT Certification NCG01-eNOT-Certification-Form-executed.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]
631.71 KB