NCC202451_Notice of Termination_20210216

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/16/2021 1:36:36 PM (NOT Submittal)
Approve by Morman, Alaina 2/18/2021 4:59:07 PM (NOT Request Review- NCC202451)
• The task was assigned to Morman, Alaina. The due date is: February 19, 2021 5:00 PM
2/16/2021 1:36 PM

1 �
NORTH CAROLINA
Enrlronmenral quallly
Certificate of NCC202451
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
7-Eleven #41360 & Future Quick Lube
Address
4650 W. Market St, Greensboro, NC
County
Guilford
Latitude
36.0701
Longitude
-79.8685
Permittee Listed
C4 CSTORE HOLDINGS II, LLC
Legally Responsible
Timothy Sittema
Individual
NC Reference No.
NCG01-2020-2451
E&SC Plan ID
Grading Permit 2989
Original NOI
26790
Tracking No.
Date COC Issued
6/15/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:
Reason for
F Project Closed -Out
Termination of
r Sale (Another Owner/Operator will apply for a new COC)
Coverage *
O Mistake or Invalid Coverage
r Other
Addional IVbre information about the basis of this request, if needed.
Explanation Project has been complete and Certificate of
Occupancy has been obtained. We'd like to
proceed with filing an NOT.

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 12/10/2020
Inspection Approval
Project Close-out 7-Eleven and Future Quick Lube Pad closing
Approval letter.pdf
Documentation
Mast be FDFformat
North Carolina General Statute 143-215.613 (i) provides that:
24.43KB
Anyperson who knowinglymakes any false statement, representation, or certification in anyapplication, record, report, plan, or other
documentfiled or required to be maintained under this Artide 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 device or method required to be operated or maintained under this Artide or rules of the
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which mayinclude a fine not to exceed ten thousand
dollars ($10,000).
17 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* Michael Isaac
Title * Project Manager
Organization* C4 CSTORE HOLDINGS 11, LLC
Date * 02/16/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 919-610-7875
NOT Certification NCG01-eNOT-Certification-Form-20201215-
Form 880.17KB
DEMLR-SW.pdf
Mast be FDF Fornat
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) [e-mail]
Original Permittee CCd on Wification Errails
Email [e-mail]

Original Site Contact GCd on Wificaiton Blails
Email [e-mail]