NCC200543_Notice of Termination_20210311

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/11/2021 11:27:01 AM (NOT Submittal)
Approve by Morman, Alaina 3/12/2021 10:38:24 AM (NOT Request Review- NCC200543)
• The task was assigned to Morman, Alaina. The due date is: March 16, 2021 5:00 PM
3/11/2021 11:27 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200543
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
Nt3y be blank (if not yet billed).
Information associated with this permit:
Project Name
7-Eleven Store No. 41144
Address
708 West Trade Street, Dallas, NC
County
Gaston
Latitude
35.3160
Longitude
-81.1860
Permittee Listed
C4 CStore Holdings II, LLC
Legally Responsible
Timothy Sittema
Individual
NC Reference No.
NCG01-2020-0543
E&SC Plan ID
3587
Original NOI
21713
Tracking No.
Date COC Issued
2/17/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 obtained 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 Mist beRYforrrat

Project Close-out Information:
Final Close-out 3/11/2021
Inspection Approval
Project Close-out 41144-Final Erosion -Close Out.pdf 330.77KB
Approval Mast be FDFfornat
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
Type Name* Barry James
Title * Partner
Organization* C4 CStore Holdings 11, LLC
Date * 03/11 /2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704-414-7472
NOT Certification 41144-Dallas NOT-Signed.pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Notification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
860.78KB