NCC200134_Notice of Termination_20210106

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 1/6/2021 12:22:46 PM (NOT Submittal)
Approve by Morman, Alaina 1/7/2021 3:34:45 PM (NOT Request Review- NCC200134)
• The task was assigned to Morman, Alaina. The due date is: January 11, 2021 5:00 PM
1 /6/2021 12:22 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200134
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
May be blank (if not yet billed).
Information associated with this permit:
Project Name
7-Eleven #1045904
Address
234 Turnersburg Highway, Statesville, NC
County
Iredell
Latitude
35.8152
Longitude
-80.8761
Permittee Listed
C4 CStore Holdings II, LLC
Legally Responsible
Timothy Sittema
Individual
NC Reference No.
NCG01-2020-0134
E&SC Plan ID
STVLE-2020-039
Original NOI
20449
Tracking No.
Date COC Issued
1/16/2020
Prior Rescission
Date populates only if COCwas already rescinded at time of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
r 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 Nbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation NlastbeRYforrrat

Project Close-out Information:
Final Close-out 10/22/2020
Inspection Approval
Project Close-out 41345-Erosion Final.pdf
Approval Mast be FDFfornat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
limf111IL'
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed 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 under this 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 may include a fine not to exceed ten thousand
dollars ($10,000).
rJ 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* Timothy Sittema
Title * Manager
Organization* C4 CStore Holdings 11, LLC
Date * 01 /06/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704-414-7472
NOT Certification 41345-NOT Signed.pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
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