NCC190362_Notice of Termination_20201209

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 12/9/2020 3:48:19 PM (NOT Submittal)
Approve by Georgoulias, Bethany 12/10/2020 1:03:30 PM (NOT Request Review- NCC190362)
* Annual fee has been waived, NOD is resolved.
• The task was assigned to Georgoulias, Bethany. The due date is: December 14, 2020 5:00 PM
12/9/2020 3:48 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190362
Coverage (COC) Enter the Certificate of Coverage Nimber
No.*
2020 Annual Fee WAIVED
Status
Information associated with this permit:
Project Name
Lee Ct.
Address
2913 Lee Ct., Greenville, NC
County
Pitt
Latitude
35.6120
Longitude
-77.4200
Permittee Listed
MJ Commercial Inc.
Legally Responsible
John Palczuk
Individual
NC Reference No.
NCG01-2019-0362
E&SC Plan ID
65869
Original NOI
11320
Tracking No.
Date COC Issued
5/23/2019
Prior Rescission
Cute populates only if CCCwas already rescinded at tirre of submttal.
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 *
r Mistake or Invalid Coverage
r Other
Addional IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting DDcurrentation if applicable.
Documentation NLstbeFOFformat
Project Close-out Information:

Final Close-out 12/9/2020
Inspection Approval
Project Close-out NOT Letter-2913 Lee Court.pdf 146.82KB
Approval Wst be RYforrrat
Documentation
North Carolina General Statute 143-215.66 (1) 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 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 Palczuk
Title * Managing Partner
Organization* MJ Commercial Inc.
Date * 12/09/2020
Email for [e-mail]
Confirmation *
Contact Telephone* 19194220709
NOT Certification NOT Letter-2913 Lee Court.pdf 146.82KB
Form Mast be PDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Original Permittee CCd on Notification Errails
Email [e-mail]
Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]