NCC204211_Notice of Termination_20210326

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 3/26/2021 5:14:55 AM (NOT Submittal)
Approve by Morman, Alaina 3/29/2021 3:22:25 PM (NOT Request Review- NCC204211)
• The task was assigned to Morman, Alaina. The due date is: March 31, 2021 5:00 PM
3/26/2021 5:14 AM

1 �
NORTH CAROLINA
Enrlronmenral quallly
Certificate of NCC204211
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
Quail Hollow Club - Tournament Transportation Center
Address
3700 GLENEAGLES RD, Charlotte, NC
County
Mecklenburg
Latitude
35.1190
Longitude
-80.8470
Permittee Listed
Quail Hollow Country Club
Legally Responsible
Tom Delozier
Individual
NC Reference No.
NCG01-2020-4211
E&SC Plan ID
LDGP-2020-00194
Original NOI
31928
Tracking No.
Date COC Issued
9/29/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
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 Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 3/11/2021
Inspection Approval
Project Close-out Transportation Center_NOT_Letter.pdf 84.78KB
Approval Mast be FDFforrrat
Documentation
North Carolina General Statute 143-215.66 (1) provides that:
Any person who knowingly makes anyfalse statement, representation, or certification in any application, record, report, plan, or other
document filed 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 ofthe
Commission implementing this Article shall be guiltyofa Class 2 misdemeanor which may include 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* Tom Delozier
Title * General Manager
Organization * Quail Hollow Club
Date * 03/26/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7046504859
NOT Certification Transportation Center_NOT_Certification.pdf
Form Mast be FDF Fornat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonWificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
62.65KB