NCC201293_NOT Signed Certification_20210525

NCGO1 Notice of Termination (NOT) Certification Form
Directions;
Print this form, complete, scan and upload to the electronic NOT (Rescission) form.
Then, mail the original form to the NC DEMLR Stormwater Program at:
Division of Energy, Mineral & Land Resources Stormwater Program
512 N. Salisbury Street, 6`h Floor
1612 Mail Service Center
Raleigh, NC 27699-1612
General Permit Certificate of Coverage (COC) No.: NCC201293
Name of Project: Circle - NT! Gum Sr nch W tern - NC 68
Per NC General Statute 143-2I5.6B (i), any person who knowingly makes any false 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.. , shall be guilty of a Class 2 misdemeanor which may
include o fine not to exceed ten thousand dollars ($10,000).
Under penalty of law, I certify that:
X 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.
Legally Responsible organizational Entity: Circle K Stores Inc.
*Legally Responsible Person: Will Rice
Title of Legally Responsible Person: Division Vice President
*Signature:
ate: 5/512021
Print Name and Title of Signed [only if authorized individual signing differs from Legally Responsible Person]:
* IMPORTANT NOTE: 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 NCGOI0000 permit.
For more information on signatory requirements, see Port IV, Section B, Item (6) of the NCG010000 permit.

North Carolina Department of Environmental Quality
Division of Energy, Mineral, and Land Resources
Stormwater Program
_ NPDES Construction Stormwater Permit
INVOICE
Annual Permit Fee
This Construction Stormwater annual fee is required by the North Carolina Administrative Code 143-
215.D(a). The fee covers the administrative costs associated with your permit. The fee is required of
any person holding a permit for any time during the annual fee period, regardless of the facility's
operating status. Failure to pay the fee by the due date will subject the permit to revocation.
Dperating without a valid permit is a violation and is subject to a $10,000 per day fine. If the permit is
revoked and you later decide a permit is needed, you must reapply, with the understanding the permit
request may be denied due to changes in environmental, regulatory, or modeling conditions.
Invoice No: NCC201293-2021
Certificate of Coverage No.: NCC201293
Effective Date: 04/01 /2020
Project Name: Circle K - NTI Gum Branch
1 Western - NC.68
Legally Responsible Person:
Meredith Rice
Circle K Stores, Inc.
1 100 Situs Court
,Raleigh, NC
27606
Invoice Date: 04/01/2021
Due Date: 05/01/2021
Annual Fee Period: Apr 2021 to Apr 2022
Annual Fee: $100
E-mail: wrice(kcirclek.com
Telephone. [phone]
Site Contact: Wes Williams
Site Contact E-mail: [e-mail]
Electronic payment option is referred. Type htt s: de .nc. ov SW-e a ments into your browser. If
you select eCheck, there is no convenience fee. The convenience fee for a credit card is 2.65% and
convenience fee for debit card is $3.95.
If you must pay with paper check, please make your check payable to "DE MLR Stormwater Program"
and include the Certificate of Coverage No. in the memo field alonx with a copy of this invoice.
A $25.40 processing fee will be charged for returned check in accordance with North Carolina General
Statute 25-3-512. Contact Aziza Selkane at [e-mail] or [phone] with questions.
Remit to: NCDEQ— Division of Energy, Mineral, and Land Resources
Stormwater Program
1612 Mail Service Center
Raleigh EEC 27699-1612
f this project has been closed out, you must submit a Notice of Termination (NOT) request here:
nc.Rov/FormsINCG01-T