NCC201748_Notice of Termination_20210519

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/19/2021 10:45:58 AM (NOT Submittal)
Approve by Morman, Alaina 5/23/2021 12:21:18 PM (NOT Request Review- NCC201748)
• The task was assigned to Morman, Alaina. The due date is: May 24, 2021 5:00 PM
5/19/2021 10:46 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201748
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
Nby be blank (iF not yet billed).
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request
until payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must
be completed first (at the NOD or NOV Review step) to ensure records are routed to the correct folder in the
repository.
However, you can reject the NOT now if it is not acceptable.
Information associated with this permit:
Project Name
Culver's Kannapolis
Address
910 Brentwood Court, Kannapolis, NC
County
Cabarrus
Latitude
35.4690
Longitude
-80.5900
Permittee Listed
Cognati Enterprises, LLC
Legally Responsible
Larry Luensman
Individual
NC Reference No.
NCG01-2020-1748
E&SC Plan ID
CABAR-2020-050
Original NOI
24857
Tracking No.
Date COC Issued
4/30/2020
Prior Rescission
Cate populates only ff OOCwas already rescinded at tirre of subaittal.
Date
Reason for Rescission/Termination Request:

Reason for r Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a newCOC)
Coverage * r Mistake or Invalid Coverage
f Other
Add ional We infornation about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Ibcurrentation if applicable.
Documentation Mast beFDFforrrat
Project Close-out Information:
Final Close-out 11/10/2020
Inspection Approval
Project Close-out Stormwater Inspection Close Out Approval.pdf 58.17KB
Approval Stormwater SCM Cert.pdf 175.91 KB
Documentation
Mast be R7Fforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes any false statement, representation, or cerlification 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 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 Article 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).
I7 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* Larry Luensman
Title * LLC Manager
Organization* Cognati Enterprises LLC
Date * 05/19/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 6183448780
NOT Certification NC eNOT.pdf 97.3KB
Form NC NOT Form.pdf 1.08MB
Mast be FDF Fornat

Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email 0Cd on Notification Errails
(Optional)
Original Permittee 0Cd on Notification Errails
Email [e-mail]
Original Site Contact 0Cd on Notificaiton Errails
Email [e-mail]