NCC204770_Notice of Termination_20220107

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 1/7/2022 3:28:44 PM (NOT Submittal)
Approve by Morman, Alaina 1/11/2022 3:49:20 PM (NOT Request Review - NCC204770)
• The task was assigned to Morman, Alaina. The due date is: January 12, 2022 5:00 PM
1/7/2022 3:28 PM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC204770
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status
2021 Annual Fee Status OPEN
May be blank (if not yet billed).
2022 Annual Fee May be blank (if not yet billed).
Status
Information associated with this permit
Project Name
CFA 4551
Address
640 Spartanburg Hwy, Hendersonville, NC
County
Henderson
Latitude
35.3074
Longitude
-82.4549
Permittee Listed
Chick-fil-A, Inc.
Legally Responsible
John Mark Wood
Individual
NC Reference No.
NCG01-2020-4770
E&SC Plan ID
SESC 2020-038
Original NOI Tracking
33587
No.
Date COC Issued
12/15/2020
Prior Rescission Date
Date populates only if COC was already rescinded at time of submittal.
Reason for Rescission/Termination Request:
Reason for • Project Closed -Out
Termination of Sale (Another Owner/Operator obtained new COC)
Coverage* Mistake or Invalid Coverage
Other
Additional More information about the basis of this request, if needed.
Explanation

Supporting Upload Supporting Documentation if applicable.
Documentation Must be PDF format
Project Close-out Information:
Final Close-out 4/5/2021
Inspection Approval
Project Close-out 4551 Erosion & Sediment
Approval 197.82KB
Inspection_Report_11_33_40_04_05_21 (1).pdf
Documentation
Must be PDF format
North Carolina General Statute 143-215.613 (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or other document
filed 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 under this 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 guilty of a Class 2 misdemeanor which may include a fine not to exceed ten thousand dollars ($10,000).
* 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 NCGO10000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
j TO -AC WLL1.4�
Type Name* R. Todd Williams
Title * Director
Organization* Chick-fil-A, Inc.
Date* 01 /07/2022
Email for [e-mail]
Confirmation *
Contact Telephone* 404-765-8000
NOT Certification NCG01 Notice of Termination (NOT) Certification
Form Form (CFA 4551).pdf 421.45KB
Must be PDF Format
Is this COC Already Ensure this COC has not been rescinded since submittal!
Rescinded?
Additional Email CC'd on Notification Emails
(Optional) [e-mail]
Original Permittee CC'd on Notification Emails
Email [e-mail]

Original Site Contact cc'd on Notificaiton Emails
Email [e-mail]