NCC200225_Notice of Termination_20210312

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/12/2021 12:01:12 PM (NOT Submittal)
Approve by Morman, Alaina 3/15/2021 4:33:04 PM (NOT Request Review- NCC200225)
• The task was assigned to Morman, Alaina. The due date is: March 17, 2021 5:00 PM
3/12/2021 12:01 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC200225
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAID
fvhy be blank (if not yet billed).
Information associated with this permit:
Project Name
Rochling Engineered Plastics GTP Addition
Address
903 Gastonia Technology Parkway, Dallas, NC
County
Gaston
Latitude
35.3010
Longitude
-81.1979
Permittee Listed
Graycor Construction Company, Inc.
Legally Responsible
Scott Skala
Individual
NC Reference No.
NCG01-2020-0225
E&SC Plan ID
3598
Original NOI
20837
Tracking No.
Date COC Issued
1/21/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
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 Project was closed out by Jonathan Boerger
at Gaston County. Reference attached final
project closeout documentation provided.

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 3/3/2021
Inspection Approval
Project Close-out FINAL - 03-03-21 Rochling Inspection Report.pdf
Approval Mast be FDFformat
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
329.92KB
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
arS_75'�%z`u.
Type Name* Scott Skala
Title * Vice President
Organization* Graycor Construction Company
Date * 03/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 708.906.7425
NOT Certification NCG01 - Termination Notice - Graycor Executed.pdf 67.55KB
Form Mast be RY Format
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 Notification BTails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]