NCC201293_Notice of Termination_20210525

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 5/25/2021 9:01:45 AM (NOT Submittal)
Approve by Morman, Alaina 5/28/2021 5:05:44 PM (NOT Request Review- NCC201293)
• The task was assigned to Morman, Alaina. The due date is: May 28, 2021 5:00 PM 5/25/2021 9:02 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC201293
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
PAID
fvby be blank (if not yet billed).
Information associated
with this permit:
Project Name
Circle K - NTI Gum Branch / Western - NC.68
Address
2231 Gum Branch Rd, Jacksonville, NC 28540, Jacksonville, NC
County
Onslow
Latitude
34.7990
Longitude
-77.4395
Permittee Listed
Circle K Stores, Inc.
Legally Responsible
Meredith Rice
Individual
NC Reference No.
NCG01-2020-1293
E&SC Plan ID
19-1503
Original NOI
23729
Tracking No.
Date COC Issued
4/1/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
r Mistake or Invalid Coverage
r Other
Addional Nbre information about the basis of this request, if needed.
Explanation Andy Bourland w/ City of Jacksonville has
updated the inspection report to include the
additionally requested information for
closeout.

Supporting Upload Supporting Ebcurrentation if applicable.
Documentation Mast bePDFforrrat
Project Close-out Information:
Final Close-out 5/19/2021
Inspection Approval
Project Close-out Circle K NTI Western Blvd -Gum Branch Rd. closeout
Approval 5.15MB
documentation.pdf
Documentation
Mast be Ft7Fforrrat
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 A tide or a rule implementing this A tide; or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Atcle; 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 ofthe
Commission implementing this Atcle 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
f ���'a
Type Name* Will Rice
Title * Division Vice President
Organization* Circle K Stores, Inc.
Date * 05/25/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 9199950843
NOT Certification 2743 - CK #6623 - NOT Certification Form - For
Form 466.97KB
Signature.pdf
Mast be RY Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification BTails
[e-mail]
CCd on Notification Erails
[e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]