NCC201539_Notice of Termination_20210414

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/14/2021 12:47:20 PM (NOT Submittal)
Approve by Morman, Alaina 4/15/2021 11:30:12 AM (NOT Request Review- NCC201539)
• The task was assigned to Morman, Alaina. The due date is: April 19, 2021 5:00 PM
4/14/2021 12:47 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201539
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
May be blank (if not yet billed).
Information associated
with this permit:
Project Name
Harris Teeter Fuel Station at Rea Farms
Address
11041 Golf Links Drive, Charlotte, NC
County
Mecklenburg
Latitude
35.0540
Longitude
-80.7715
Permittee Listed
Lanier Site Services, Inc
Legally Responsible
William Van Sickle
Individual
NC Reference No.
NCG01-2020-1539
E&SC Plan ID
LDGP-2020-00053
Original NOI
24418
Tracking No.
Date COC Issued
4/17/2020
Prior Rescission
Date populates only if COCwas already rescinded at time of submittal.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 Nbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation NlastbeRYforrrat

Project Close-out Information:
Final Close-out 2/11/2021
Inspection Approval
Project Close-out HT Fuel Rea Farms_NOT.pdf 83.33KB
Approval Mast be FDFforrrat
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 Amide; 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* William Van Sickle
Title * Secretary
Organization * Lanier Site Services, Inc.
Date * 04/14/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704-587-3022
NOT Certification NOT Certification Form 13Apri12021.pdf
Form Mast be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
390.2KB