NCC200446_Notice of Termination_20210204

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/4/2021 1:28:57 PM (NOT Submittal)
Approve by Morman, Alaina 2/8/2021 10:16:47 AM (NOT Request Review- NCC200446)
• The task was assigned to Morman, Alaina. The due date is: February 9, 2021 5:00 PM
2/4/2021 1:29 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200446
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
Nby be blank (if not yet billed).
Information associated
with this permit:
Project Name
Wood Spring Suites
Address
7007 Macfarlance Blvd, Charlotte, NC
County
Mecklenburg
Latitude
35.2853
Longitude
-80.7696
Permittee Listed
Liberty
Legally Responsible
Adam Mikkelson
Individual
NC Reference No.
NCG01-2020-0446
E&SC Plan ID
LDGP-2019-00172
Original NOI
21479
Tracking No.
Date COC Issued
2/5/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.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 IVbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation MstbeRYforrrat

Project Close-out Information:
Final Close-out 2/3/2021
Inspection Approval
Project Close-out Grading PermitNotice0fTermination_20210203_05... 83.83KB
Approval Mast be FDFforrrat
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 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 Artcle shall be guiltyofa Class 2 misdemeanor which mayinclude 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* Adam Mikkelson
Title * Presdent
Organization * Liberty WS Charlotte Belgate, LLLP
Date * 02/04/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 3214411048
NOT Certification NOT Cert Form.pdf
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Notification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
187.47KB