NCC204483_Notice of Termination_20211012

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/12/2021 11:09:02 AM (NOT Submittal)
Approve by Morman, Alaina 10/12/2021 2:03:15 PM (NOT Request Review- NCC204483)
• The task was assigned to Morman, Alaina. The due date is: October 15, 2021 5:00 PM
10/12/2021 11:09 AM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of
NCC204483
Coverage (COC)
Enter the Certificate of Coverage Nmber
No.*
2020 Annual Fee Status
2021 Annual Fee Status
OPEN
Nby be blank (if not yet billed).
Information associated
with this permit:
Project Name
Harbor Freight - Wilkesboro, NC
Address
Two River Drive Ext, Wilkesboro, NC
County
Wilkes
Latitude
36.1512
Longitude
-81.1816
Permittee Listed
Henbell Properties, LLC
Legally Responsible
Troy Jordan
Individual
NC Reference No.
NCG01-2020-4483
E&SC Plan ID
WILKE-2021-005
Original NOI
32559
Tracking No.
Date COC Issued
10/7/2020
Prior Rescission
Cate populates only if COCwas already rescinded at time of submittal.
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
Additional IVbre information about the basis of this request, if needed.
Explanation
Supporting upload Supporting Documentation if applicable.
Documentation MstbeRYforrrat

Project Close-out Information:
Final Close-out 10/11/2021
Inspection Approval
Project Close-out WILKE-2021-005 Harbor Freight - Wilkesboro,
Approval 38.84KB
closure report 10-5-2021.pdf
Documentation
Mist be FDFforrrat
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* Dennis Trotter
Title * Managing Member
Organization* Henbell Properties, LLC
Date * 10/12/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 706-736-1031
NOT Certification NCG01-eNOT-Certification-Form-20210514-
Form 2.53MB
DEMLR-SW.pdf
Mist be FDF Fbrrrat
Is this COC Already Ensure this CCChas not been rescinded since subrrittal!
Rescinded?
Additional Email
(Optional)
Original Permittee
Email
CCd on Notification Errails
[e-mail]
CCd on Notification Erails
[e-mail]
Original Site Contact CCd on Notificaiton Firnils
Email [e-mail]