NCC210769_Notice of Termination_20220208

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 2/8/2022 1:32:59 PM (NOT Submittal)
Approve by EADS\amorman1 2/11/2022 5:12:49 PM (NOT Request Review - NCC210769)
• The task was assigned to Morman, Alaina. The due date is: February 11, 2022 5:00 PM
2/8/2022 1:33 PM

NORTH CAROLINA
Rrf OmFkm&tral Qualrly
Certificate of NCC210769
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status
2021 Annual Fee Status May be blank (if not yet billed).
2022 Annual Fee OPEN
Status May be blank (if not yet billed).
Information associated with this permit:
Project Name
Jamestown Chick-fil-A
Address
Grandover Village Shopping Center, City of Jamestown, NC
County
Guilford
Latitude
36.0018
Longitude
-79.9044
Permittee Listed
Chick-fil-A, Inc.
Legally Responsible
John Mark Wood
Individual
NC Reference No.
NCG01-2021-0769
E&SC Plan ID
20-08-GCRP-05784
Original NOI Tracking
42928
No.
Date COC Issued
2/16/2021
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Date populates only if COC was already rescinded at time of submittal.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 11/4/2021
Inspection Approval
Project Close-out Grandover Final Letter for NOT.pdf 17.06KB
Approval Must be PDF format
Documentation
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
7—A00 WiL_L-1,4„m
Type Name* R. Todd Williams
Title* Director
Organization* Chick-fil-A, Inc.
Date * 02/08/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 4047658000
NOT Certification Jamestown Chick-fil-A NOT.pdf
Form 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]
63KB