NCC200691_Notice of Termination_20210325

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/25/2021 1:43:33 PM (NOT Submittal)
Approve by Morman, Alaina 3/25/2021 4:24:04 PM (NOT Request Review- NCC200691)
• The task was assigned to Morman, Alaina. The due date is: March 30, 2021 5:00 PM
3/25/2021 1:43 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200691
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
CaptiveAire Expansion
Address
305 Northbrook Drive, Youngsville, NC
County
Franklin
Latitude
36.0000
Longitude
-78.0000
Permittee Listed
CAS Youngsville, LLC
Legally Responsible
Brandon Hafner
Individual
NC Reference No.
NCG01-2020-0691
E&SC Plan ID
Frank-2020-006
Original NOI
22078
Tracking No.
Date COC Issued
2/24/2020
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Cate populates only if COCwas already rescinded at time of submittal.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 3/23/2021
Inspection Approval
Project Close-out Close Out Report for NOT.pdf 35.69KB
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 any recording or monitoring deice or method required to be operated or maintained under this Article or rules of the
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
� 0,4
Type Name* Huneka Bower
Title * Administrative Coordinator
Organization* CaptiveAire Systems, Inc
Date * 03/25/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 919-815-9933
NOT Certification 210325 - 305 Northbrook executed NOT form.pdf
Form Mast be FDF Forrrst
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCdonNotification Bmils
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]
325.7KB