NCC200420_Notice of Termination_20201030

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 10/30/2020 8:40:54 AM (NOT Submittal)
Approve by Georgoulias, Bethany 10/30/2020 10:52:48 AM (NOT Request Review- NCC200420)
• The task was assigned to Georgoulias, Bethany. The due date is: November 4, 2020 5:00 PM
10/30/2020 8:40 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200420
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Sheetzat Fernwood
Address
5323 Ramsey Street, Fayetteville, NC
County
Cumberland
Latitude
35.1330
Longitude
-78.8780
Permittee Listed
Sheetz, Inc.
Legally Responsible
Steven Augustine
Individual
NC Reference No.
NCG01-2020-0420
E&SC Plan ID
CUMBE-2020-076
Original NOI
21413
Tracking No.
Date COC Issued
2/4/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 8/7/2020
Inspection Approval

Project Close-out NOT COG Inspection Sheetz#685 NC Fayetteville
Approval 56.47KB
(Fernwood).pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.6E (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 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 device 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
Type Name* Steven P. Augustine
Title * VP of Store Development
Organization* Sheetz, Inc.
Date * 10/30/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 9194379859
NOT Certification Fayetteville, NC (Fernwood Dr) NOT Certification
Form 10.30.2020.pdf
Wst be RY Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Wification Emails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]
172.7KB