NCC201085_Notice of Termination_20210212

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/12/2021 12:15:36 PM (NOT Submittal)
Approve by Morman, Alaina 2/15/2021 11:31:23 AM (NOT Request Review- NCC201085)
• The task was assigned to Morman, Alaina. The due date is: February 17, 2021 5:00 PM
2/12/2021 12:15 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201085
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank (if not yet billed)
Information associated with this permit:
Project Name
O Reilly Auto Parts
Address
6409 Burlington Road, Whitsett, NC
County
Guilford
Latitude
36.0632
Longitude
-79.6062
Permittee Listed
3D Development Holdings, LLC
Legally Responsible
Charles Dunstan
Individual
NC Reference No.
NCG01-2020-1085
E&SC Plan ID
19-11-GCCP-08789
Original NOI
23241
Tracking No.
Date COC Issued
3/19/2020
Prior Rescission
Date populates only if OOC was already rescinded at tirre of submittal.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 *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 1/27/2021
Inspection Approval
Project Close-out Letter of Credit397.pdf
Approval Mist be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
447.25KB
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* Charles Dunstan
Title * Manager
Organization* 3D Development Holdings, LLC
Date * 02/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7062678050
NOT Certification NCG01-eNOT-Certification-Form-20201215-
Form 855KB
DEMLR-SW.pdf
Mist be FDF Forrrat
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 57ails
Email [e-mail]