NCC200533_Notice of Termination_20201103

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 11/3/2020 12:55:36 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/3/2020 2:18:15 PM (NOT Request Review- NCC200533)
• The task was assigned to Georgoulias, Bethany. The due date is: November 6, 2020 5:00 PM
11/3/2020 12:55 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200533
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Dollar General- Lizard Lick
Address
1800 Lizard Lick Road, Zebulon, NC
County
Wake
Latitude
35.8170
Longitude
-78.3747
Permittee Listed
Vanguard Ventures LLC
Legally Responsible
George Barnes
Individual
NC Reference No.
NCG01-2020-0533
E&SC Plan ID
SEC-027007-2019
Original NOI
21704
Tracking No.
Date COC Issued
2/17/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 10/8/2020
Inspection Approval

Project Close-out 10.08.20 Certificate of Completion Sedimentation
Approval and Erosion Control_DG Wendell (Lizard Lick), 46.08KB
Documentation
NC.pdf
Mist be FDFforrrat
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 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 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
6.o�r WJWTx�s
Type Name* George Venters
Title * member/manager
Organization* Vanguard Ventures
Date * 11/03/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 919-459-2601
NOT Certification NOT Lizard Lick.pdf 29.78KB
Form Mist be RY Forrrat
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCdonKbtificationBmils
Email [e-mail]
Original Site Contact CCd on Wificaiton BTails
Email [e-mail]