HomeMy WebLinkAboutNCC190429_Notice of Termination_20210616Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 6/16/2021 3:20:49 PM (NOT Submittal)
Approve by Morman, Alaina 6/17/2021 2:29:28 PM (NOT Request Review- NCC190429)
• The task was assigned to Morman, Alaina. The due date is: June 21, 2021 5:00 PM
6/16/2021 3:20 PM
1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC190429
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status PAID
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
Circle K- NTI Bragg/Vass
Address
1921 N Bragg Blvd, Spring Lake, NC
County
Cumberland
Latitude
35.1970
Longitude
-78.9890
Permittee Listed
Circle K Stores, Inc.
Legally Responsible
Will Rice
Individual
NC Reference No.
NCG01-2019-0429
E&SC Plan ID
CUMBE-2019-067
Original NOI
11562
Tracking No.
Date COC Issued
5/31/2019
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Cate populates only ff OOCwas already rescinded at tirre of subaittal.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 information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Ibcurrentation if applicable.
Documentation Mast beFDFformat
Project Close-out Information:
Final Close-out 6/14/2021
Inspection Approval
Project Close-out 2491 - CK #4593 - Sedimentation Stromwater
Approval 29.15KB
Inspection Report - Final.pdf
Documentation
Mast be FDFforrrat
North Carolina General Statute 143-215.66 (1) provides that:
Anyperson who knowinglymakes anyfalse 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 knowinglymakes a false statement
of a material fact in a rulemaking proceeding or contested case underthis Article; orwho falsifies, tampers with, or knowinglyrenders
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 notto 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* Will Rice
Title * Division Vice President
Organization * Circle K Stores, Inc.
Date * 06/16/2021
Email for wwilliam@circlek.com
Confirmation *
Contact Telephone* 919-774-6700
NOT Certification 2491 - CK #4593 - NOT Certification Form - For
Form 465.3KB
Signature.pdf
Mast be FDF Format
Is this COCAlready Ensure this OOChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Emils
kelsey@Wmcocorp.com
CCd on Notification Errails
wrice@circlek.com
Original Site Contact CCd on Notificaiton Errails
Email wwilliam@circlek.com