NCC202007_Notice of Termination_20220613

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/13/2022 10:38:53 AM (NOT Submittal)
Approve by Clark, Paul B 6/18/2022 2:59:14 PM (NOT Request Review - NCC202007)
• The task was assigned to Clark, Paul B by round robin distribution 6/13/2022 10:38 AM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: June 16, 2022 5:00 PM
6/13/2022 10:38 AM

Use this form to submit a Notice of Termination (NOT) request for a project covered under the N.C. NPDES
General Permit for Construction Activities NCGO10000 (or NCG250000). If approved, the Certificate of Coverage
(COC) will be rescinded.
Certificate of NCC202007
Coverage (COC) No.* Enter the Certificate of Coverage Number
2020 Annual Fee Status 2021 Annual Fee Status 2022 Annual Fee Status
May be blank if N/A PAST DUE PAST DUE
May be blank if N/A May be blank if N/A
This permittee owes a fee that is PAST DUE and has a pending NOD or NOV. Do not approve this NOT request until
payment is resolved. If this NOT request is acceptable, payment may be waived if applicable, but that action must be
completed first (at the NOD or NOV Review step) to ensure records are routed to the correct folder in the repository.
However, you can reject the NOT now if it is not acceptable.
Once payment is resolved, reload this review task to see the revised fee status.
Information associated with this permit:
Project Name Dilworth Hotel
Lots Covered by this This information is especially helpful when more lots were added with Modifications since the original permit
Permit COC (if issuance.
applicable) No longer visible on the initial form (data not captured from initial application)
Address 216 E. Worthington Ave, Charlotte, NC
County Mecklenburg
Latitude 35.2101
Longitude-80.8585
Permittee Listed OMS Dilworth, LLC
Legally Responsible Lauren Chavis
Individual
NC Reference No. NCG01-2020-2007
E&SC Plan ID LDGP-2020-00088
Original NOI Tracking 25620
No.
Date COC Issued 5/15/2020
Prior Rescission Date Date populates only if COC was already rescinded at time of submittal.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 Land was sold, new owner did not take previous plans
Additional More information about the basis of this request, if needed.
Explanation
Supporting Upload Supporting Documentation if applicable.
Documentation Grading Permit Withdrawal Letter.pdf
Must be PDF format
Project Close-out Information:
Erosion Control Plan
Close-out Date
Erosion Control Plan Must be PDF format
Close-out
Documentation
North Carolina General Statute 143-215.613 (i) provides that:
181.56KB
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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
WKW-M,
Type Name* Lauren Chavis
Title* Corporate Manager
Organization * OMS Dilworth
Date * 06/13/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 704-543-0017 Ext.101
NOT Certification 2022.06.09 - NOT Form.pdf 34.02KB
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)
Original Permittee CC'd on Notification Emails
Email [e-mail]
Original Site Contact CC'd on Notificaiton Emails
Email [e-mail]