NCC201874_Notice of Termination_20210708

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 7/8/2021 11:21:08 AM (NOT Submittal)
Approve by Morman, Alaina 7/9/2021 8:58:32 AM (NOT Request Review- NCC201874)
• The task was assigned to Morman, Alaina. The due date is: July 13, 2021 5:00 PM 7/8/2021 11:21 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC201874
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status PAST DUE
fvby 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
Dollar General - Claremont Store #21683
Address
May 10, Claremont, NC
County
Catawba
Latitude
35.6766
Longitude
-81.1149
Permittee Listed
Teramore Construction
Legally Responsible
Zach Crumley
Individual
NC Reference No.
NCG01-2020-1874
E&SC Plan ID
CBPR-04-2020-34427
Original NOI
25235
Tracking No.
Date COC Issued
5/7/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.
Date
Reason for Rescission/Termination Request:

Reason for f Project Closed -Out
Termination of r Sale (Another Owner/Operator obtained a newCOC)
Coverage * r Mistake or Invalid Coverage
r Other The job was canceled. NOI is not needed
Add ional Mxe information about the basis of this request, if needed.
Explanation The job was canceled. NOI is not needed.
Supporting Upload Supporting Ibcurrentation if applicable.
Documentation Fwd_ [External] NOT for COC No. NCC201874.pdf 123.49KB
Mast be RYfornat
Project Close-out Information:
Final Close-out
Inspection Approval
Project Close-out Mist beFDFfornat
Approval
Documentation
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 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 notto 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* Zach Crumley
Title * Senior VP
Organization* Teramore Development
Date * 07/08/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 2295164289
NOT Certification NOT_Claremont.pdf 351.71KB
Form Mast be FDF Fornat

Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional)
Original Permittee CCdonNotificationBmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]