HomeMy WebLinkAboutNCC191814_Notice of Termination_20210218Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 2/18/2021 2:44:08 PM (NOT Submittal)
Approve by Morman, Alaina 2/19/2021 3:59:48 PM (NOT Request Review- NCC191814)
• The task was assigned to Morman, Alaina. The due date is: February 23, 2021 5:00 PM
2/18/2021 2:44 PM
1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC191814
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
PAID
2021 Annual Fee Status
Nbybeblank (if not yet billed).
Information associated
with this permit:
Project Name
Dollar General # 20342
Address
1771 Motor Road, Winston Salem, NC
County
Forsyth
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Teramore Development
Legally Responsible
Zach Crumley
Individual
NC Reference No.
NCG01-2019-1814
E&SC Plan ID
A/P#EN1900070
Original NOI
15773
Tracking No.
Date COC Issued
9/11/2019
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Date populates only if OOC was already rescinded at tirre of submittal.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 12/16/2020
Inspection Approval
Project Close-out sir DOLLAR GENERAL --MOTOR RD. 12-16-20.pdf 125.45KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowingly renders
inaccurate anyrecording 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 notto 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* Zach Crumley
Title * Senior VP
Organization* Teramore Construction
Date * 02/18/2021
Email for tglass@teramore.net
Confirmation *
Contact Telephone* 2295164289
NOT Certification NOT Certification Form —Motor Road.pdf 353.84KB
Form Mast be FDF 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
tglass@teramore.net
Original Site Contact CCd on Notificaiton BTails
Email tglass@teramore.net