NCC200316_Notice of Termination_20200911

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/11/2020 8:42:06 AM (NOT Submittal)
Approve by Georgoulias, Bethany 9/11/2020 8:56:08 AM (NOT Request Review- NCC200316)
• The task was assigned to Georgoulias, Bethany. The due date is: September 16, 2020 5:00 PM
9/11/2020 8:42 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200316
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Henderson Dollar General
Address
N. Oliver Drive, Sandy Creek, NC
County
Vance
Latitude
36.0000
Longitude
-78.0000
Permittee Listed
Par 5 Development Group, LLC
Legally Responsible
Jody Bland
Individual
NC Reference No.
NCG01-2020-0316
E&SC Plan ID
VANCE-2020-001
Original NOI
21106
Tracking No.
Date COC Issued
2/10/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 9/8/2020
Inspection Approval

Project Close-out Henderson NC E&S Permit Termination Approval
Approval 174.07KB
Letter VANCE-2020-001.pdf
Documentation
Mist be FL7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowinglyrenders
inaccurate anyrecording 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 notto 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
1 I. rv.�Wfx
Type Name* Jamie S. Encinosa
Title * Vice President
Organization* Par 5 Development Group, LLC
Date * 09/11 /2020
Email for [e-mail]
Confirmation *
Contact Telephone* 910-944-0881
NOT Certification Henderson NC Signed Notice of Termination
Form 341.07KB
form.pdf
Mist be RY Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wif ication Bi ails
Email [e-mail]
Original Site Contact CCd on Kbtificaiton Bmils
Email [e-mail]