NCC205640_Notice of Termination_20210902

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 9/2/2021 3:46:58 PM (NOT Submittal)
Approve by Morman, Alaina 9/3/2021 4:57:00 PM (NOT Request Review- NCC205640)
• The task was assigned to Morman, Alaina. The due date is: September 7, 2021 5:00 PM
9/2/2021 3:47 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC205640
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
Culvers Restaurant Winston-Salem, NC
Address
2973 Fairlawn Drive, Winston-Salem, NC
County
Forsyth
Latitude
36.1422
Longitude
-80.2924
Permittee Listed
Square Properties Winston-Salem, LLC
Legally Responsible
Vikramkumar Patel
Individual
NC Reference No.
NCG01-2020-5640
E&SC Plan ID
EN2000176
Original NOI
38082
Tracking No.
Date COC Issued
12/9/2020
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Cate populates only if COCwas already rescinded at tirre of subrrittal.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 *
U Mistake or Invalid Coverage
r Other
Ad d i o n a I Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Dxurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 8/20/2021
Inspection Approval
Project Close-out sir CULVER RESTAURANT 8-20-21 n.o.t..pdf 83.05KB
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
Type Name* Vikramkumar Patel
Title * Owner
Organization* Square Properties Winston-Salem, LLC
Date * 09/02/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 732-551-9192
NOT Certification eNOT Certification Form.pdf
Form Mast 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 CCdonNotificationBmils
Email vikran-41171 @yahoo.com
Original Site Contact CCd on Notificaiton Errails
Email [e-mail]
549.53KB