NCC191840_Notice of Termination_20201124

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 11/24/2020 3:25:59 PM (NOT Submittal)
Approve by Georgoulias, Bethany 11/30/2020 8:44:06 AM (NOT Request Review- NCC191840)
• The task was assigned to Georgoulias, Bethany. The due date is: November 27, 2020 5:00 PM
11 /24/2020 3:26 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC191840
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
Information associated with this permit
Project Name
Lawndale Office Building
Address
3524 Lawndale Dr., Greensboro, NC
County
Guilford
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
MBRJ Investments, LLC
Legally Responsible
Michael Bateman
Individual
NC Reference No.
NCG01-2019-1840
E&SC Plan ID
2955
Original NOI
15775
Tracking No.
Date COC Issued
9/13/2019
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 10/6/2020
Inspection Approval

Project Close-out Erosion Control Final Inspection Report.pdf 580.71KB
Approval Mast be FDFforrrat
Documentation
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 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
6?r1116?W C0041'_1 1?1
Type Name* Michael C Bateman
Title * Member/Manager
Organization* MBRJ Investments, LLC
Date * 11 /24/2020
Email for [e-mail]
Confirmation * M
Contact Telephone* 336-707-3063
NOT Certification Scan0002.pdf 353.84KB
Form Mast be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since submttal!
Rescinded?
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Emils
Email [e-mail]