NCC213685_Notice of Termination_20220622

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 6/22/2022 4:52:24 PM (NOT Submittal)
Approve by Clark, Paul B 6/27/2022 5:56:30 PM (NOT Request Review - NCC213685)
• The task was assigned to Clark, Paul B by round robin distribution 6/22/2022 4:52 PM
The task was assigned to DEMLR NCG01 NOT Review Team. The due date is: June 27, 2022 5:00 PM
6/22/2022 4:52 PM

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(COC) will be rescinded.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 NCC213685
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 May be blank if N/A OPEN
May be blank if N/A
Information associated with this permit:
Project Name
AUTOZONE
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
4626 Hicone Road, Greensboro, NC
County
Guilford
Latitude
36.0000
Longitude
-80.0000
Permittee Listed
Blackburn Construction Inc.
Legally Responsible
David Blackburn
Individual
NC Reference No.
NCG01-2021-3685
E&SC Plan ID
2988
Original NOI Tracking
56715
No.
Date COC Issued
6/22/2021
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Date populates only if COC was already rescinded at time of submittal.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:
Erosion Control Plan 6/22/2022
Close-out Date
Erosion Control Plan PE Certification Package_Signed.pdf
345.32KB
Close-out 2021-05-03_Sand Filter Certification_Draft. pdf
1.23MB
Documentation
2021-05-04_Greensboro Drainage Plans
—Record
1.7MB
Drawings.pdf
As -Built Survey_Sand Filter.pdf
487.64KB
As -Built Survey_Storm Line.pdf
319.16KB
Site-5176_2022-06-15_InCompliance.pdf
656.39KB
City of Greensboro - Termination of Grading Permit
736.55KB
Letter.pdf
Must be PDF format
North Carolina General Statute 143-215.613 (1) 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 NCG010000 General Permit. For more information on signatory requirements, see Part IV, Section B, Item
(6) of that permit.
Signature
��ar�?i� �rrara�G�rp�
Type Name* David Blackburn
Title* CEO
Organization * Blackburn Construction, Inc.
Date * 06/22/2022
Email for [e-mail]
Confirmation*
Contact Telephone* 6625134194
NOT Certification Signed Notice of Termination Certification Form.pdf 71.63KB
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]