NCC201836_Notice of Termination_20210503

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/3/2021 2:31:38 PM (NOT Submittal)
Approve by Georgoulias, Bethany A 5/4/2021 10:25:06 AM (NOT Request Review- NCC201836)
• Georgoulias, Bethany A reassigned the task to Georgoulias, Bethany A 5/4/2021 10:18 AM
The task was assigned to Morman, Alaina. The due date is: May 6, 2021 5:00 PM 5/3/2021 2:31 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201836
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
Back Yard Burger - Gastonia
Address
3415 E. Franklin Blvd, Gastonia, NC
County
Gaston
Latitude
35.0000
Longitude
-81.0000
Permittee Listed
Primax Properties, LLC
Legally Responsible
Brad Owen
Individual
NC Reference No.
NCG01-2020-1836
E&SC Plan ID
3519
Original NOI
25108
Tracking No.
Date COC Issued
5/6/2020
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Date populates only if COCwas already rescinded at time of submittal.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 NlastbeRFforrrat

Project Close-out Information:
Final Close-out 10/30/2020
Inspection Approval
Project Close-out 10-30-20 Backyard Burger Insp. Report.pdf 307KB
Approval Must 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 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* Brad Owen
Title * Construction Manager
Organization * Primax Properties, LLC
Date * 05/03/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 7049995780
NOT Certification NCG01-eNOT-Certification-Form-20210305-
Form DEMLR-SW.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification En -ails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
952.61 KB