NCC201519_Notice of Termination_20210309

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 3/9/2021 1:19:28 PM (NOT Submittal)
Approve by Morman, Alaina 3/9/2021 1:50:43 PM (NOT Request Review- NCC201519)
• The task was assigned to Morman, Alaina. The due date is: March 12, 2021 5:00 PM
3/9/2021 1:19 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201519
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
Rockingham W. Green Street Dollar General
Address
W. Green Street, Rockingham, NC
County
Richmond
Latitude
34.9409
Longitude
-79.7767
Permittee Listed
Par 5 Development Group, LLC
Legally Responsible
Jody Bland
Individual
NC Reference No.
NCG01-2020-1519
E&SC Plan ID
RICHM-2020-003
Original NOI
24356
Tracking No.
Date COC Issued
5/1/2020
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Date populates only if OOC was already rescinded at tirre of submittal.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 obtained 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 3/2/2021
Inspection Approval
Project Close-out Rockingham W Greene Street Dollar
Approval 36.91 KB
Genera I_RICHM-2020-003_3-2-2021. pdf
Documentation
Mist 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 * Jamie S. Encinosa
Title * Vice President
Organization * Par 5 Development Group, LLC
Date * 03/09/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 910-944-0881
NOT Certification Rockingham NC W Greene Street Signed NOT.pdf 46.4KB
Form Mast be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton BTails
Email [e-mail]