NCC204403_Notice of Termination_20210721

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 7/21/2021 3:00:01 PM(NOT Submittal)
Approve by Morman,Alaina 7/23/2021 3:38:22 PM(NOT Request Review-NCC204403)
• The task was assigned to Morman,Alaina.The due date is:July 26,2021 5:00 PM 7/21/2021 3:00 PM

" RequestNOT • Construction Stormwater
1 i
�a•aThis formto request Notice of • • for •co\erage under •
NORTH CAROLINA General - for • i i• Activities Qr�arrry
Certificate of NCC204403
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status May be blank(if not yet billed).
Information associated with this permit:
Project Name Dollar General-Broad Creek
Address 1210 Broad Creek Road, New Bern, NC
County Craven
Latitude 35.1166
Longitude -76.9711
Permittee Listed Glandon Forest Equity
Legally Responsible George Barnes
Individual
NC Reference No. NCG01-2020-4403
E&SC Plan ID Crave-2021-008
Original NOI 32329
Tracking No.
Date COC Issued 10/6/2020
Prior Rescission Cate populates only if COC was already rescinded at tine of subrrittal.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* U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre inforrration about the basis of this request,if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFforrrat

Project Close-out Information:
Final Close-out 7/7/2021
Inspection Approval
Project Close-out Broad Creek EC CLose OUt LEtter.pdf 27.77KB
Approval Mast be FDFforrrat
Documentation
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 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 deice or method required to be operated or maintained under this Article or rules ofthe
Commission implementing this Article 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
°'t7f,PAM/4
Type Name* George Barnes
Title* Manager
Organization* Glandon Forest Equity, LLC
Date* 07/21/2021
Email for [e-mail]
Confirmation
Contact Telephone* 919-459-2601
NOT Certification NOT Broad Creek.pdf 33.68KB
Form Mast be FDF Format
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Erails
(Optional)
Original Permittee CCd on Wification Bmils
Email [e-mail]
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]

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