NCC200258_Notice of Termination_20210212

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/12/2021 8:49:26 AM (NOT Submittal)
Approve by Morman, Alaina 2/15/2021 11:22:24 AM (NOT Request Review- NCC200258)
• The task was assigned to Morman, Alaina. The due date is: February 17, 2021 5:00 PM
2/12/2021 8:49 AM

1 �
NORTH CAROLINA
Enrlronmenral quallly
Certificate of
NCC200258
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
Quality Mart - Union Cross
Address
1980 Pecan Lane, Kernersville, NC
County
Forsyth
Latitude
36.0826
Longitude
-80.1111
Permittee Listed
Quality Oil Company
Legally Responsible
Rodney Cheek
Individual
NC Reference No.
NCG01-2020-0258
E&SC Plan ID
EN1900152
Original NOI
20835
Tracking No.
Date COC Issued
1/22/2020
Prior Rescission
Clete populates only if COCwas already rescinded at time of submittal.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 2/11/2021
Inspection Approval
Project Close-out Sedimentation report from City - Quality Oil 2-11-
Approval 21.pdf 76.23KB
Documentation
Mast be FDFforrrat
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 ofthe
Commission implementing this Article 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* Rodney S. Cheek
Title * Vice President Construction
Organization * Quality Oil Company, LLC
Date * 02/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 3367223441
NOT Certification NOT Certification Form 021221.pdf 67.59KB
Form Mast be PDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Erails
CCd on Notification Bmils
[e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]