NCC200074_Notice of Termination_20210216

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/16/2021 9:02:37 AM (NOT Submittal)
Approve by Morman, Alaina 2/18/2021 3:37:35 PM (NOT Request Review- NCC200074)
• The task was assigned to Morman, Alaina. The due date is: February 19, 2021 5:00 PM
2/16/2021 9:02 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200074
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
CIRCLE K - R&R 2723188
Address
1065 BETHANIA-RURAL HALL ROAD, RURAL HALL, NC
County
Forsyth
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
CIRCLE K STORES, INC
Legally Responsible
WILL RICE, JR
Individual
NC Reference No.
NCG01-2020-0074
E&SC Plan ID
EN1900168
Original NOI
20269
Tracking No.
Date COC Issued
1/9/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 1/20/2021
Inspection Approval
Project Close-out sir CIRCLE K RURAL HALL 1-20-21.pdf 127.16KB
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
AiCt
Type Name* Will Rice
Title * Division Vice President
Organization * Circle K Stores, Inc.
Date * 02/16/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 2529465175
NOT Certification 2679 -Circle K #3188 -NOT Certification Letter. pdf 99.73KB
Form Mast be FDF Fornat
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 Errails
Email [e-mail]