NCC200421_Notice of Termination_20210817

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 8/17/2021 4:04:44 PM (NOT Submittal)
Approve by Morman, Alaina 8/18/2021 11:30:56 AM (NOT Request Review- NCC200421)
• The task was assigned to Morman, Alaina. The due date is: August 20, 2021 5:00 PM
8/17/2021 4:04 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC200421
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
PAID
fvby be blank (if not yet billed).
Information associated
with this permit:
Project Name
Ray Self Storage Spring Garden Street
Address
3121 Spring Garden Street, Greensboro, NC
County
Guilford
Latitude
36.0610
Longitude
-79.8454
Permittee Listed
Ray Self Storage, LLC
Legally Responsible
Alan Ray
Individual
NC Reference No.
NCG01-2020-0421
E&SC Plan ID
Ray Self Storage - Spring Garden Street
Original NOI
21422
Tracking No.
Date COC Issued
2/4/2020
Prior Rescission
Cate populates only if COCwas already rescinded at tirre of subrrittal.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 We inforrration about the basis of this request, if needed.
Explanation Construction is complete and Erosion
Control Permit has been closed per attached
report.

Supporting upload Supporting Documentation if applicable.
Documentation Mist beFDFformat
Project Close-out Information:
Final Close-out 7/21/2021
Inspection Approval
Project Close-out Site-5012_2021-07-21_InCompliance.pdf
Approval Mast be FDFformat
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
580.8KB
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 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 not to exceed ten thousand
dollars ($10,000).
17 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* Alan Ray
Title * Owner
Organization * Ray Self Storage, LLC
Date * 08/17/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 3368558020
NOT Certification Document_ 20210817_0001.pdf 31.4KB
Form Mast be RY Format
Is this COCAlready Ensure this OOChas not been rescinded since subnittal!
Rescinded?
Additional Email CCd on Notification Emails
(Optional) [e-mail]
Original Permittee CCd on Notification BTails
Email [e-mail]

Original Site Contact CCd on Notificaiton Bmils
Email [e-mail]