NCC205823_Notice of Termination_20211013

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/13/2021 1:26:55 PM (NOT Submittal)
Approve by Morman, Alaina 10/13/2021 4:58:40 PM (NOT Request Review- NCC205823)
• The task was assigned to Morman, Alaina. The due date is: October 18, 2021 5:00 PM
10/13/2021 1:26 PM

1 �
NORTH CAROLINA
Enrlronmenral Quallly
Certificate of NCC205823
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
7-Eleven Mount Holly
Address
11112 Mount Holly Road, Charlotte, NC
County
Mecklenburg
Latitude
35.3010
Longitude
-80.9870
Permittee Listed
C4 CStore Holdings II, LLC
Legally Responsible
Timothy Sittema
Individual
NC Reference No.
NCG01-2020-5823
E&SC Plan ID
LDGP-2020-00226
Original NOI
39192
Tracking No.
Date COC Issued
1/5/2021
Prior Rescission
Date populates only if OOC was already rescinded at tirre of submittal.
Date
Reason for Rescission/Termination Request:
Reason for
F Project Closed -Out
Termination of
r Sale (Another Owner/Operator obtained a new COC)
Coverage *
O Mistake or Invalid Coverage
r Other
Additional Nbre information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Docurrentation if applicable.
Documentation Mist beFDFformat

Project Close-out Information:
Final Close-out 10/7/2021
Inspection Approval
Project Close-out 41253-Grading Permit NOT.pdf 84.61KB
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
� 5- cT r1r•
Type Name* Peter B. Pappas
Title * Manager
Organization* C4 CStore Holdings 11, LLC
Date * 10/13/2021
Email for [e-mail]
Confirmation *
Contact Telephone* 704-414-7472
NOT Certification 41253-CoC NOT.pdf
Form Mast be FDF Forrrat
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]
491.42KB