NCC203499_Notice of Termination_20210813

Action History (UTC-05:00)Eastern Time(US&Canada)
Subrrit by Anonymous User 8/13/2021 2:18:28 PM(NOT Submittal)
Approve by Morman,Alaina 8/13/2021 4:30:39 PM(NOT Request Review-NCC203499)
• The task was assigned to Morman,Alaina.The due date is:August 18,2021 5:00 PM
8/13/2021 2:18 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 NCC203499
Coverage (COC) Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status OPEN
May be blank(if not yet billed).
Information associated with this permit:
Project Name Mountain Island Chick-fil-A
Address 3821 Corning Place,City of Charlotte, NC
County Mecklenburg
Latitude 35.0000
Longitude -81.0000
Permittee Listed Chick-fil-A, Inc.
Legally Responsible John Mark Wood
Individual
NC Reference No. NCG01-2020-3499
E&SC Plan ID LDC-2019-00288
Original NOI 29807
Tracking No.
Date COC Issued 8/13/2020
Prior Rescission Cate populates only if COC was already rescinded at tirre of subrrittal.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 IVbre inforrration about the basis of this request,if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation Mist beRYforrrat

Project Close-out Information:
Final Close-out 8/9/2021
Inspection Approval
Project Close-out Ckick Fil A NOT.Charlotte.8.9.21.pdf 85.36KB
Approval Mist 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 Amide;or who knowingly makes a false statement
of a material fact in a rulemaking proceeding or contested case under this 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 of the
Commission implementing this Artcle 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
,Ta W 444W k Weep
Type Name* John Mark Wood
Title* Director
Organization* Chick-fil-A, Inc.
Date* 08/13/2021
Email for [e-mail]
Confirmation
Contact Telephone* 4047658000
NOT Certification NCG01 Notice of Termination(NOT)Certification
Form 3.05MB
Form-Mountain Island Chick-fil-A.pdf
Mist be FDF Forrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email CCd on Notification Errails
(Optional) [e-mail]
Original Permittee CCdonNotificationErrails
Email [e-mail]
Original Site Contact CCd on%tificaiton Errails
Email [e-mail]

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